Comprehensive Perinatal Services Program Protocols



5556884186118400Comprehensive Perinatal Services Program ProtocolsLos Angeles County8978903335020005166360333692500-5010148620125March 1, 2017Los Angeles County Department of Public Health600 S. Commonwealth Ave., Suite 800, Los Angeles, CA 90005(213)639-6419 ? 1, 2017Los Angeles County Department of Public Health600 S. Commonwealth Ave., Suite 800, Los Angeles, CA 90005(213)639-6419 ? Perinatal Services Program ProtocolsTable of Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc477957706 \h 3Client Orientation Protocol PAGEREF _Toc477957707 \h 4Prenatal Assessment and Individualized Care Plan Protocol PAGEREF _Toc477957708 \h 6Personal Information PAGEREF _Toc477957709 \h 9Economic Resources PAGEREF _Toc477957710 \h 13Housing PAGEREF _Toc477957711 \h 14Transportation PAGEREF _Toc477957712 \h 15Current Health Practices PAGEREF _Toc477957713 \h 16Pregnancy Care PAGEREF _Toc477957714 \h 20Educational Interests PAGEREF _Toc477957715 \h 25Nutrition: Anthropometric PAGEREF _Toc477957716 \h 27Nutrition: Biochemical PAGEREF _Toc477957717 \h 29Nutrition: Clinical PAGEREF _Toc477957718 \h 30Nutrition: Dietary PAGEREF _Toc477957719 \h 32Coping Skills PAGEREF _Toc477957720 \h 36Group Education Protocol PAGEREF _Toc477957721 \h 41Mandated Reporting Protocol PAGEREF _Toc477957722 \h 42Postpartum Assessment and Individualized Care Plan Protocol PAGEREF _Toc477957723 \h 45Baby PAGEREF _Toc477957724 \h 47Clinical-Delivery PAGEREF _Toc477957725 \h 47Clinical-Infant PAGEREF _Toc477957726 \h 48Clinical-Maternal PAGEREF _Toc477957727 \h 48Nutrition: Anthropometric PAGEREF _Toc477957728 \h 49Nutrition: Biochemical (Postpartum) PAGEREF _Toc477957729 \h 49Nutrition: Clinical PAGEREF _Toc477957730 \h 50Nutrition: Dietary PAGEREF _Toc477957731 \h 51Nutrition: Infant PAGEREF _Toc477957732 \h 51Psychosocial PAGEREF _Toc477957733 \h 53Health Education PAGEREF _Toc477957734 \h 57Health Education: Family Planning PAGEREF _Toc477957735 \h 58Health Education: Infant Safety & Care PAGEREF _Toc477957736 \h 59Other PAGEREF _Toc477957737 \h 59Protocol Attachment Checklist PAGEREF _Toc477957738 \h 60 CPSP Protocol Signature PageName of CPSP Practice: FORMTEXT ?????Address: FORMTEXT ?????City/State/ZIP: FORMTEXT ?????Phone: FORMTEXT ?????The undersigned have reviewed and approved the attached CPSP protocols:CPSP Supervising PhysicianName and Credentials (typed): FORMTEXT ?????Signature:Date: FORMTEXT ?????-15811515875000IntroductionThis protocol template was developed by the Los Angeles County Department of Public Health for use by providers of the Comprehensive Perinatal Services Program (CPSP) in Los Angeles County. These protocols are to be used with the CPSP Provider Handbook, 2015 Edition, and the CPSP Steps to Take Guidelines, 2015 Edition. Protocols are site-specific. Interventions and materials recommended in the protocols may be replaced by those preferred by your clinic’s CPSP Provider or Coordinator. Adapt the protocols to reflect your actual practice as needed. For more ideas on developing site-specific protocols, refer to the section of the CPSP Provider Handbook called Implementing and Maintaining CPSP. Copies of your customized protocols must be submitted to your local CPSP Coordinator within 6 months of CPSP certification. Protocols are a staff resource and should be shared with and readily accessible for all CPSP practitioners, including Comprehensive Perinatal Health Workers (CPHWs). The protocols are generally organized in the following manner: 1) the question as it appears on the assessment tool, 2) information about the topic, 3) reference to the appropriate section of Steps to Take Guidelines, 4) specific interventions designed to meet needs identified by asking the client that particular question, and 5) referral or other resources.For further instructions, information or technical assistance regarding CPSP, you may call your local CPSP Coordinator at the following numbers:Los Angeles County(213) 639-6419City of Long Beach(562) 570-4271City of Pasadena(626) 744-6092Client Orientation ProtocolPurpose: To inform the client about her prenatal and postpartum care and services available through the Comprehensive Perinatal Services Program (CPSP)To review danger signs and what to do if they happenStaffing:The following level of staff will conduct Client Orientation (mark all that apply): Comprehensive Perinatal Health Worker (CPHW)RN/LVNOther:________________________________________________Procedure:Client orientation will be provided to each new prenatal CPSP client (mark all that apply):At confirmation of pregnancyAt first obstetric visit At initial CPSP assessmentOther: ______________________________________________Refer to Steps to Take Guidelines (STT): First Steps - Orientation to Your Services and Health Education – What to Discuss at the First VisitConfidentiality is a critical component of CPSP. During the client orientation, limits of the client’s confidentiality should be outlined such as mandatory reporting laws for child abuse, domestic violence, etc. Inform the client that other members of the health care team will share the information among themselves, on a need to know basis, as needed to deliver the best care possible. Provide a copy of the office’s HIPAA Privacy Practices to the client. Initial client orientation must be individual and face-to-face. At least one unit (minimum 8 minutes) must be providedAt the initial client orientation, a CPSP practitioner will review with the client a copy of the STT Health Education handout, Welcome to Pregnancy Care, and will discuss the importance and content of postpartum care. Required topics include:Perinatal services to be provided, including CPSPWho will provide servicesWhere services will be provided Danger signs of pregnancy & what to doClient rights and responsibilities (including client confidentiality)Additional orientation may be needed before a new procedure or referral. Review orientation topics previously discussed as needed. If the client has transferred care from another CPSP provider, repeat the client orientation to inform the client of practices at this site.Additional topics/handouts to discuss during client orientation include:Substances to avoid during pregnancy (STT Health Education handout – Pregnant Steps for a Healthy Baby)Group classes available (at the clinic, hospital, or community)Routine lab tests and procedures, including HIV (STT Health Education handout – What You Should Know About HIV)Prenatal Screening Program (formerly AFP)Delivery site options, including locations, information on tours available, pre-admission information requested by the hospital and routine practices of the hospitalFinancial responsibilityFetal kick counts (22-28 wks.) (STT Health Education handout – Count Your Baby’s Kicks)Other information about services and procedures such as ultrasound, glucose tolerance testing, stress testing, amniocentesis, etc., as these issues arise. Explain the procedures, who will do them, and why they are important. Reinforce any pre- or post-procedure instructions.Provide postpartum orientation to services and referrals; for example, lactation support services, on-going primary care for the clientDocumentation:Documentation is important for communication and billing and should be clear and completeDocument all topics discussed, either on the Client Orientation Checklist or Progress Notes. Include orientation content, date, number of minutes, and staff signature and CPSP titleWritten consent to participate in CPSP is not requiredIf the client declines to participate in CPSP, a note must be made in the client’s medical record which includes any particular reason the client gives for declining services. The client may begin CPSP services at any point throughout her pregnancy, so if she declines during the initial orientation, you may offer at a later time. Prenatal Assessment and Individualized Care Plan ProtocolPurpose:To help the client have a healthy baby by identifying her strengths, as well as problems and learning needs that affect the pregnancy during the first, second and third trimester of her pregnancyTo develop an Individualized Care Plan to address those needs and build on those strengthsPrenatal Assessment Staffing The following level of staff will conduct Prenatal Assessments and develop the Individualized Care Plan (mark all that apply): Comprehensive Perinatal Health Worker (CPHW)RN/LVNRegistered DietitianHealth EducatorSocial WorkerOther:________________________________________________Supervising Provider Oversight Indicate how the supervising physician will provide oversight of the CPSP services provided by all CPSP practitioners (CPHW, RN, LVN, RD, etc.):The supervising physician (or his/her designee) will review and sign (select at least one):Prenatal Assessment & Individualized Care Plan 2nd Trimester Reassessment3rd Trimester ReassessmentPostpartum Assessment & Individualized Care PlanThe supervising physician maintains responsibility of CPSP services but will delegate day-to-day oversight to: ___________________________________________________________________________________ (Must be licensed clinician only – PA, NP, CNM)_____________________________________________________________________________________ Supervising Provider SignatureDateProcedure:Refer to STT Guidelines: First Steps - AssessmentThe Prenatal Assessment and Individualized Care Plan Tool is designed to be completed by any qualified CPSP practitioner, as defined in Title 22, Section 51179.7. The practitioner must be listed on the provider application or staff update form. A CPSP practitioner must complete the assessment face-to-face with the client in a private setting. It is not appropriate for a client to complete this form by herself or to be conducted over the phone. Conduct the assessment in a conversational manner, and use language appropriate to the client’s culture and education level when asking about the topics included in the plete the initial assessment as early as possible in the client’s prenatal care, ideally within 4 weeks of entry to care. The initial assessment may occur in the first, second, or third trimester depending on when the client begins her prenatal care. Reassessment must occur in each of the following trimester(s). For example, if a client enters prenatal care in the second trimester, enter the date of the initial assessment in the “Initial” space and “N/A” in the 2nd trimester space at the top of the first page. All questions must be asked (unless they are not applicable) at the initial assessment, no matter when in the pregnancy that initial assessment occurs. Responses that are shaded are possible risk factors and usually will require additional questioning for clarification. If risks are identified, intervention(s) are needed according to the protocol, such as education, counseling, and/or referral to other CPSP support services practitioners, community based organizations, public resources, or specialists.Reassessments must occur in the trimester(s) following the initial assessment. The purpose of the reassessments is to follow up on unresolved issues and identify any new problems. Before conducting the reassessments, review the previous assessments and individualized care plan. Not all questions need to be asked again after the initial assessment. The numbers of the reassessment FILLIN \* MERGEFORMAT questions that must be repeated are shaded so they can be easily recognized during plete all sections of the assessment form during the appropriate trimester, and use N/A for questions that are not applicable. If the client declines to respond to a question, document “declines to state” on the form and continue with the assessment.At the completion of the assessment, summarize the needs and strengths that have been identified and assist the client in prioritizing them. Work with her to set reasonable goals and plans and document them on the Individualized Care Plan Summary.Documentation:Client Information:Date/Weeks: Date the assessment is conducted and the gestation of the pregnancy in weeksClient Name: Client’s first name, middle initial, and last nameDate of Birth: Client’s month, date, and year of birthHealth Plan: Client’s health plan, if applicableID Number: If applicable, the ID number assigned to your client by your clinicProvider: The physician or other provider in charge of the client’s overall OB/CPSP careHospital: Hospital or location where the client plans to deliverCase Coordinator: Name and CPSP title of the Case CoordinatorEDD: Estimated Date of Delivery, or the due date, is the calculated birthdate of the infant using the first day of the client’s last menstrual period. Charts or “OB wheels” can be used for the calculation. Write in the month/day/year.Diagnosis of OB High Risk Condition: Review the OB record and any notes documented by the OB provider and summarize any high risk conditions noted here. Examples are hypertension, diabetes, sexually transmitted infection. Gravida: Write in the number of times the client has been pregnant including this one. All pregnancies should be counted regardless of whether they resulted in a live birth or not.Para: Write in the number of previous deliveries resulting in infants weighing 500 grams or more or having a gestational age of 20 weeks or more, whether alive or dead at delivery. A multiple fetal pregnancy (twins, triplets, etc.) counts as only one delivery.Individualized Care Plan & SummaryThe Individualized Care Plan (ICP) is integrated into the assessment form and provides a simple way to document the interventions described in the protocols. The ICP consists of education topics, specific handouts in the Steps to Take Guidelines (STT), and referrals to clinic or community resources. The protocols contain additional background information and details about each risk/problem and appropriate interventions and should always be reviewed before planning an intervention. Based on the client’s specific needs, mark the appropriate STT section(s) or handout(s) used to provide education or counseling. Each referral should be documented with the name of the person/agency and the date the referral was made. Acknowledging the client’s past and current strengths empowers her to make positive changes during the current pregnancy and in the future. Client strengths should be summarized in the space provided above the Individualized Care Plan Summary. Review STT Guidelines: First Steps - Essential Elements of Every Client Interaction for examples of appropriate strengths.Problems identified on the assessment should be prioritized and summarized in the Individualized Care Plan Summary (ICP). The ICP will be a quick, brief way for the client’s CPSP team to view the findings of her assessment. In the first three columns, indicate the question number and a brief summary of the problem and goal. Use the last column to document any updates or outcomes at the time of the 2nd and 3rd trimester reassessments and postpartum, as applicable. Describe the client’s progress towards resolving the problem. For example, was the problem resolved? What has changed since the last assessment? This information can include whether she has followed through on the referrals provided, or made changes to her behavior such as her eating or exercise habits, etc.93726049530Briefly write a description of the problem, risk, or concern.00Briefly write a description of the problem, risk, or concern.2451735189230Describe the client’s goal (what will be accomplished because of the interventions.)00Describe the client’s goal (what will be accomplished because of the interventions.)5143522225Question number from the assessment.00Question number from the assessment.4490085107950Document the client’s progress towards resolving the problem at the time of the 2nd and 3rd trimester reassessments, as well as postpartum if applicable.00Document the client’s progress towards resolving the problem at the time of the 2nd and 3rd trimester reassessments, as well as postpartum if applicable.53333652984500-28194022733000Once the Prenatal Assessment and Individualized Care Plan documentation has been completed, the assessor must sign their name, and write their CPSP title, the date, and the amount of time (in minutes) that it took to complete BOTH the Prenatal Assessment and the Individualized Care Plan (ICP). CPSP progress notes should also be legibly signed and the writer’s CPSP title, date and minutes spent should also be included. Personal InformationIndividualized Care PlanClient age:Less than 12 years12-17 years18-34 years35 years or olderClients Age 17 or YoungerTeens may be at higher risk medically, psychosocially, nutritionally, and in terms of their health education needs. Teenage pregnancy is associated with an increased risk of preterm delivery & low birth weight. Teen girls may limit their food intake in order to stay slim and hide their pregnancy. Such poor eating habits can lead to health problems for her and baby.Additionally, a minor (age 12 or older) can receive pregnancy-related care (including abortion) without her parents’ permission, as long as she is capable of giving informed consent. A pregnant minor is eligible for a type of Medi-Cal called “sensitive services” or “minor consent services.” Neither the provider nor Medi-Cal may contact the parents. Teens may also need referrals to AFLP, Cal-Learn, home visitation program, or other teen mother programs. When a client has been the victim of sexual abuse, she is at risk for engaging in sexual activity at an early age. If you are providing services for a pregnant teen, listen carefully for any information that she may have a history of sexual abuse, may have been coerced/forced to have sex, or had sex under any other circumstances that were not voluntary (i.e., she was too intoxicated to give consent, unconscious, etc.). You may need to refer your client to a social worker for further evaluation and support, and/or make a child abuse report.Interventions: If you suspect sexual assault or other abuse toward the teen, you are mandated to report to the LA County Child Protective Hotline at: 1-800-540-4000. Refer to the clinic’s mandated reporting protocol on pages 43-45Refer to STT First Steps: Approaching Clients of Different Ages and STT Psychosocial: Teen Pregnancy and ParentingRefer client to Text4Baby by texting BABY to 511411 (English) or BEBE to 511411 (Spanish). Text4Baby is a free service that will send her 3 health tips per week during pregnancy and the first year of the baby’s lifeRefer to your local Adolescent Family Life Program (AFLP), which offers case management for pregnant and parenting teensOffer a referral to a home visitation program such as Nurse Family Partnership (NFP) or Early Head StartRefer to social workerClients Over 35Women over 35 years of age (advanced maternal age) at time of delivery may need additional genetic screening. Interventions:Refer to provider to determine if a genetic counseling referral is needed and provide orientation as neededRefer to STT First Steps: Approaching Clients of Different AgesRefer client to Text4Baby by texting BABY to 511411 (English) or BEBE to 511411 (Spanish). Text4Baby is a free service that will send her 3 health tips per week during pregnancy and the first year of the baby’s lifeAre you:MarriedSingleLiving with partnerDivorced/SeparatedIn a relationshipWidowedOther______________________________This question may give you an idea of the client’s support system. Interventions:Refer to social worker or applicable community resources for assistance identifying or accessing social support as neededHow long have you lived at your current home? Over one yearUnder one year, previously lived:___________________ □ Familiar with local area □ Not familiar with local areaPlace of birth:________________________________________If the client has lived in their current home for less than a year or has recently emigrated from another country, she may have a weaker support system, be less familiar with community resources, and need more orientation and guidance. A client’s place of birth may give information about the client’s cultural background.Interventions: Refer to STT First Steps: Cultural Considerations, Cross-Cultural Communication, and Clients with Alternative Health Care Experiences and STT Psychosocial: New ImmigrantProvide additional orientation to the client as neededDo you plan to stay in this area for the rest of your pregnancy?YesNo, explain: _________________________________ Unsure, explain: ______________________________If the client does not plan to stay in the area, she will need assistance to transfer her care and need counseling on the importance of ongoing and consistent prenatal care. Interventions: Discuss the benefits and importance of regular prenatal care for her and the babyIf the client is a Medi-Cal Managed Care Member and is staying in the same county, refer to the appropriate Member Services phone number for help finding a new providerIf the client is leaving the county, she will need to call the Department of Social Services in that county to transfer her Medi-Cal and get a referral to a new providerHow many years of school have you completed?0-8 years9-11 years12-16 years16+ yearsYears of school completed may give you a general idea of the client’s reading and comprehension levels.Clients under the age of 18 are required by law to attend school unless they have graduated or passed the California High School Proficiency Exam. The Cal-Learn program helps pregnant and parenting teens to attend and graduate from high school or its equivalent. Pregnant/parenting teens who are receiving CalWORKs are required to participate in Cal-Learn if they are under the age of 19 and haven’t received a high school diploma/GED.Interventions: Provide written information based on her education/reading levelIf under 18 and has not completed school, provide referral to a school program for pregnant/parenting teensIf over 18, offer referrals to Adult School, English as a Second Language (ESL), or GED programs if the client is interestedWhat language do you prefer to speak?What language do you prefer to read?EnglishSpanishOther: ______________EnglishSpanish Other: ________________Clarify with the client what language she feels most comfortable expressing herself, and what language she would like to receive informational materials.Interventions: Refer to STT First Steps: Cross Cultural Communication, Dealing with Language Barriers, and Guidelines for Using InterpretersContact interpreter service if neededWhich of the following bests describes how you read:Like to read and read oftenCan read, but don’t read very oftenCan’t readIf the client doesn’t read very often or can’t read, tailor your health education services to her ability. For example, use more audio-visual materials, verbal instruction, or written materials with a lot of pictures.Interventions: Provided verbal/visual/written information appropriate for client’s abilityRefer to STT First Steps: Low Literacy GuidelinesOffer referral to public library or adult literacy programFather of baby: Name:______________________________________________Language:___________________________________________Education:___________________________________________Age:________________________________________________This response can give you additional information about her support system. You are not required to ask a teen under the age of 18 the age of the baby’s father. However, if the teen tells you the age of the father of her baby, you may be required to make a mandated child abuse report depending on the client’s age and the age of the father of the baby. For example, if the client is under 14, and the father of the baby is 14 or older, you must make a mandated child abuse report. You must also report if the client is under age 16, and the father of the baby is 21 or older. You can also make a child abuse report any time based on your clinical judgement, regardless of the client’s/partner’s ages if you have reasonable suspicion that the client engaged in sexual intercourse that was coerced/forced or was in any other way not voluntary (i.e., she was too intoxicated to give consent, unconscious, etc.). If parents are unmarried, establishing paternity is not automatic. The process should be started as soon as possible. Establishing paternity will give the child rights such as the right to financial support from both parents, access to parent’s medical benefits, etc. Unmarried parents can establish paternity by signing the voluntary Declaration of Paternity at the hospital or after the child is born. For more information about California’s Paternity Opportunity Program (POP) visit: childsup.resources/establishpaternity.aspx Interventions: Provide referral for legal assistance where the client can obtain advice regarding paternal responsibilities, including child supportEducate the client about options for declaring paternity. Refer to STT Psychosocial: Teen Pregnancy and Parenting (even if client is not a teen)You are not required to ask the teen under 18 the age of the baby’s father. However, if the teen client tells you the age of the father of her baby, review “When Mandated Reporters Must Report Sexual Activity by Minors in California” (see ) for guidance on whether or not you need to file a reportIf you suspect sexual assault or other abuse toward the teen, you are mandated to report to the LA County Child Protective Hotline at: 1-800-540-4000. Refer to the clinic’s mandated reporting protocol on pages 43-45Refer to STT Psychosocial: Teen Pregnancy and Parenting and Child Abuse and Neglect for more informationIs this a planned pregnancy?YesNo, describe: _________Is this a wanted pregnancy?YesUnsureNo, describe:___________Planned pregnancies may mean different things to different cultures. Using open ended questions can help you understand what her beliefs are about pregnancy and family planning. Let her know that you will be asking her questions about family planning later in the pregnancy. Interventions:Ask if her unplanned or unwanted pregnancy was due to her partner interfering with her birth control or forcing her to have unprotected sex. If so, inform the client that there are birth control methods her partner does not have to know about that she can discuss with the providerEncourage client to wait at least 18 months before becoming pregnant again. This will give her time to recover and bond with her babyReview & discuss STT Psychosocial: Unwanted Pregnancy, and handouts Uncertain About Pregnancy? and ChoicesProvide information about Baby Safe Surrender Program, where a parent may drop off a newborn baby within 72 hours (3 days) of birth to any hospital or fire station with no questions asked. The Safe Surrender hotline is: 1-877-222-9723Offer referral to adoption servicesRefer to OB provider if she would like more information about abortion and a referral to abortion services (if not offered in your clinic)Offer referral to social worker for counselingAre you thinking about abortion or adoption?NoYes: □ Adoption □ AbortionHow do you feel about being pregnant now?If the client expresses negative feelings and thoughts about being pregnant, ask for more information to identify appropriate ways to support her. Interventions:Offer a referral to a social worker or local mental health clinic if client is feeling troubled, depressed or anxiousRefer to home visitation programIf she has financial or legal concerns, review & discuss: STT Psychosocial: Financial Concerns and Legal/Advocacy Concerns0-13 Weeks:GoodUnsureTroubled Explain:______________________14-27 Weeks:GoodUnsureTroubled Explain:______________________28-40 Weeks:GoodUnsureTroubled Explain:______________________How does the father of the baby feel about the pregnancy? _________________________________________________Your family? _______________________________________Your friends? _______________________________________If the father of the baby is not supportive, you can help the client identify supportive family and/or friends to provide assistance during pregnancy and postpartum. Clients may also find support through their church or other groups/organizations they are involved with in the community.Interventions:If client lacks support, provide referral to home visitation programRefer to social worker for assistance identifying additional supportProvide information on declaring paternity (per STT PSY: Teen Pregnancy and Parenting – even if client is not a teen)Review/discuss STT Psychosocial: Financial Concerns and Legal/Advocacy ConcernsEconomic Resourcesa) Are you currently working or going to school? No Yes, Type of school/work: ______________ Hours per week: __________________b) Do you plan to work or go to school while you are pregnant?YesNoc) Do you plan to return to work/school after baby is born? YesNoThis question provides information about the client’s financial resources and any safety issues in her school or work environment. This is also an opportunity to discuss childcare and breastfeeding plans if she plans to return to work or school after the baby is born. Interventions:If she is under 18 (and has not graduated or passed the California High School Proficiency Exam) she is required by law to attend school. Refer to local school program for pregnant/parenting teensRefer to STT Health Education: Workplace Safety and handout Keep Safe at WorkRefer to STT Psychosocial: Financial Concerns, Legal/Advocacy ConcernsReview and discuss information on pumping/storing breastmilk per STT Nutrition: BreastfeedingRefer to childcare resourceWill the father of the baby provide financial support for you and the baby?YesNoUnsureOther sources of financial help:_________________________This question gives an indication of the father’s involvement and the client’s sources of financial support. Support can include not only money, but also groceries, infant supplies, transportation, etc. Interventions:Refer to STT Psychosocial: Financial Concerns for information on the father’s requirement to pay child supportRefer to STT Psychosocial: Legal/Advocacy ConcernsRefer to Los Angeles County Child Support Services Department at: 1-866-901-3212Are you receiving any of the following?All pregnant Medi-Cal recipients should be eligible for WIC and must be referred. Interventions:Refer to STT First Steps: Making Successful Referrals, Women, Infants and Children (WIC) Supplemental Nutrition Program, and STT Psychosocial: Financial ConcernsRefer to local WIC ProgramYesNoWICCalFresh (Food Stamps)CalWORKsMedi-CalEmergency Food AssistancePregnancy disability benefitsOther:_______________________In the last year, did you or anybody in your household ever eat less or skip meals because there wasn't enough money for food?No Yes, explain:_________________________Skipping meals and/or eating less due to financial problems during the last year may put the client at risk for poor diet and poor nutrition during her pregnancy. If the client doesn’t have enough to eat, it could also poorly affect her birth outcome. In addition to referring to WIC and CalFresh in Question #15, it might also be helpful to educate the client about shopping on a budget, and/or provide information about local food banks where additional free food items may be obtained. Interventions: Refer to STT Nutrition: Getting Healthy Foods and STT Nutrition handouts: Tips for Healthy Food Shopping, You Can Buy Healthy Food on a Budget, and You Can Stretch Your Dollars: Choose These Easy Meals and SnacksRefer to food bankHousingWhat type of housing do you currently live in?The client may need referrals for housing resources if she does not have a stable housing situation or if she feels her housing situation is unsafe. Unstable and/or unsafe housing can be a major source of stress. Safety issues can include environmental safety issues like gang activity.Asking about who lives in her home can give information about whether the home is overcrowded. The health of the client may be at risk if the home is overcrowded or has water leaks, mold, cockroaches, or other issues. Additionally, if her home was built before 1978 and there is chipping or peeling paint, she may be exposed to toxic levels of lead which can increase the risk of fetal growth restriction, maternal hypertension, and miscarriage. It can also be poisonous for any infants or children in the house and cause long-term mental and behavioral problems.Interventions:Refer to STT Psychosocial: Financial Concerns for information about housing optionsIf she says she feels that her housing is not safe for her, ask for more information and make referrals as neededRefer to the LA County Housing Resource Center to help clients find affordable, special-needs, accessible, and emergency housing at: 1-877-428-8844Refer to an emergency shelter if she is homeless. If you are not able to find an emergency shelter that can accept her, notify your supervisor before she leaves the clinic. The medical provider or other licensed practitioner is responsible for appropriate evaluation and referralsIf her home was built before 1978 and/or has peeling/chipping paint:Refer to the provider to see if a blood lead test is neededRefer to the LA County Childhood Lead Poisoning Prevention Hotline at: 1-800-LA-4-LEADHouseHotel/MotelApartmentFarm Worker CampTrailer ParkEmergency ShelterPublic HousingCarOther:______________________Any changes in housing?14-27 Weeks:NoYes, explain:_____________________28-40 Weeks:NoYes, explain:_____________________Members of household (not including client):Number of adults:______________Relationship to client:___________________________________Number of children:______________Relationship to client:___________________________________Was your house or apartment built before 1978?□ No□ Yes□ UnsureIs there chipping or peeling paint inside or outside the home?□ No□ Yes□ UnsureIs your current housing safe and adequate for you and yourchildren)?0-13 Weeks:YesNo, explain:_______________________14-27 Weeks:YesNo, explain:_______________________28-40 Weeks:YesNo, explain:_______________________Do any of your children or your partner’s children live with someone else?N/A NoYes, explain:_______________________________If yes, provide a brief description of where the children live and why. Parents separated from their children may have issues with grief and loss.Interventions: If the children have been removed from the home by the Department of Child & Family Services (Child Protective Services) or a custody order, offer referral to parenting classes or social workerRefer to STT Psychosocial: Parenting Stress, New Immigrant, and Legal/Advocacy Concerns as appropriateRefer to National Parent Helpline at: 1-855-4A PARENT or 1-855-427-2736Refer to local family support/counseling or child abuse prevention programRefer to a social worker or local mental health clinic for issues with grief, loss, and/or guiltDo you have the following where you live?Plumbing, electricity, and safe food storage/preparation areas are important for health, safety, and nutrition. If the client does not have any of these items, ask her for more information about the problem and make appropriate referrals as needed. Interventions: As needed, refer to STT Nutrition: Cooking and Food Storage, Food Safety and handouts When You Cannot Refrigerate: Choose These Foods, Tips for Cooking and Storing Food, and Don’t Get Sick From the Foods You EatIf her housing is not safe or appropriate, refer to Housing Resources such as the LA County Housing Resource Center to help her find housing at: 1-877-428-8844Refer to Housing Resources for information about tenant’s rightsRefer to local fire department for smoke alarm information0-13 Wks14-27 Wks28-40 WksYesNoYesNoYesNoToiletStove/place to cookTub/showerElectricityRefrigeratorHot/cold waterPhoneSmoke detectorsWindows that open/closeDo you have a gun in your home?NoYes, how is it stored? ____________________________Guns are a leading cause of death for children. In homes where there is violence, guns lead to a higher risk of injury or death. If there are guns kept in the home, the parents should make sure they are stored safely. Interventions:Counsel parents who have guns at home to keep them unloaded in a locked case, with the ammunition locked separately, and out of reach of childrenIf the client would like to get rid of a gun, educate her that most police stations allow people turn in their unwanted gunsTransportationWill you have any problems coming to your appointments orDiscuss how keeping appointments and attending classes are important for the health of the baby and help the client identify solutions. Remind client about clinic policy to cancel appointments. If the client depends on another person for transportation, encourage them to be a part of her prenatal care. Interventions: Offer patient choice of appointment/class timesOffer bus tokens or taxi vouchers if possibleProvide referrals for childcare or transportation servicesattending classes due to transportation, childcare, work, school, or another reason? 0-13 Weeks:NoYes: ______________________________14-27 Weeks:NoYes: ______________________________28-40 Weeks:NoYes: ______________________________a) When you ride in a car, do you use seatbelts?b) Do you know how to use a seat belt when pregnant?AlwaysSometimes NeverYesNoIf she has questions, counsel the patient on how to wear the seatbelt safely. The lap strap should go under the belly. The shoulder strap should go between her breasts and to the side of her belly. Interventions: Review and discuss STT Health Education handout: Pregnant? Steps for a Healthy BabyDo you have a car seat for the new baby?As a way to make sure the client is following the law, the delivery hospital will not allow the baby to go home without being secured in a car seat. By the third trimester, the client should have an infant car seat and be able to describe or demonstrate its correct usage.Interventions:Refer to STT Health Education: Infant Safety and HealthReview and discuss STT Health Education handout: Keep Your Baby Safe and HealthyGive referral to free or low-cost car seat programDiscuss whether delivery hospital will provide car seat to client prior to discharge14-27 Weeks:YesNo28-40 Weeks:YesNoHow will you get to the hospital?This is an opportunity to discuss client’s plans for care of her other children and transportation to the delivery hospital during labor. This also offers you a chance to discuss what to do if labor starts too early.Interventions: Refer to STT Health Education: Preterm Labor and Hospital OrientationRefer to STT Health Education handout: If Your Labor Starts Too EarlyAssist client in scheduling tour of delivery hospitalOffer bus tokens or taxi vouchers if possibleProvide referrals for childcare or transportation services14-27 weeks:__________________________________UnsureNo transportation available28-40 weeks:__________________________________UnsureNo transportation availableCurrent Health PracticesDo you have a primary care doctor for you and your family?YesNoDiscuss the importance of preventive care for the client and her family, including well woman visits. Interventions: Refer to STT Appendix: Introduction to Managed CareGive referral to primary care provider or community clinicDo you have a doctor for your baby?The Child Health & Disability Prevention (CHDP) Program provides free health check-ups to help children and teens stay healthy. Children in low to moderate income families are eligible for free immunization shots and health check-ups.Interventions: Refer to STT Health Education: Infant Safety and Health Review and discuss STT Health Education handouts: When Your Newborn Baby is Ill and Your Baby Needs to be ImmunizedRefer to CHDP provider14-27 Weeks:NoYes, who?__________________28-40 Weeks:NoYes, who?__________________Have you been to a dentist in the last 6 months?Lack of dental care can seriously impact a pregnant woman’s health, possibly leading to chronic infection, difficulty eating, and may even be linked to preterm labor. Denti-Cal is a benefit that covers preventive dental services for ALL pregnant women with Medi-Cal, including Presumptive Eligibility (PE).Interventions: Refer to STT Health Education: Oral Health During Pregnancy.Review and discuss STT Health Education handouts: Prevent Gum Problems When You Are Pregnant, See a Dentist When You Are Pregnant, and Keep Your Teeth and Mouth Healthy! Protect Your Baby TooRefer to registered dietitian if dental problems are causing her pain while eatingGive referral to dentist if neededYesNob) Do you have any problems with your teeth, gums or mouth such as toothaches, bleeding gums, or a bad taste or smell?0-13 Weeks:NoYes:_________________________14-27 Weeks:NoYes:_________________________28-40 Weeks:NoYes:_________________________How many total hours doHow many total min/hours This is an opportunity to discuss pregnancy discomforts and possible solutions. Too much or too little sleep may be a symptom of perinatal depression and may need further assessment and referral. Interventions: Discuss using extra pillows for joint or back discomfortIf the client is unable to relax, offer deep breathing, visualization and relaxation techniquesReview and discuss STT Psychosocial: Emotional or Mental Health Concerns, Depression, and How Bad are Your Blues?Notify provider if patient is sleeping too much (more than 10 hours) or too little (less than 6 hours)Refer to social worker or local mental health clinic if problems with sleeping are due to stress or moodRefer to the PHQ-4 depression screening at question 92 and follow the appropriate protocols if her score is more than 2you sleep at night?do you nap during the day?0-13 Weeks:0-13 Weeks:14-27 Weeks:14-27 Weeks:28-40 Weeks:28-40 Weeks:Do you exercise?Regular and safe exercise can reduce stress, control weight gain, and help a woman prepare for childbirth. Provide education about the benefits of prenatal exercise, including Kegels. Interventions:Refer to STT Health Education: Safe Exercise and LiftingIf needed, refer to provider for discussion of vigorous exercise (lifting heavy weights, running, etc.) during pregnancyReview and discuss STT Health Education handouts: Exercises To Do When You Are Pregnant, Stay Active When You Are Pregnant, and Keep Safe When You Exercise Give referral to free or low-cost exercise classes or facilities in your area0-13 Weeks:NoYes, type/frequency:____________________14-27 Weeks:NoYes, type/frequency:____________________28-40 Weeks:NoYes, type/frequency:____________________Are you currently smoking or using any tobacco productsSmoking or using any tobacco products during pregnancy can lead to serious problems like preterm birth, miscarriage, and problems with the placenta. The infant of a mother who smokes is at higher risk of low birth weight, Sudden Infant Death Syndrome (SIDS), and learning disabilities.Secondhand smoke can have serious effects on both the mother and the baby. Children who are exposed to secondhand smoke experience more respiratory problems and are at greater risk for SIDS. Interventions: Refer to STT Health Education: Tobacco Use and/or Secondhand Tobacco SmokeReview and discuss STT Health Education handout: You Can Quit SmokingGive referral to local smoking cessation programRefer to California Smokers’ Helpline for free counseling or information on secondhand smoke at: 1-800-NO-BUTTS or 1-800-45-NO-FUME (Spanish)Refer to provider for additional counseling on smoking cessation(including hookah or vaping)?0-13 Weeks:NoYes: How much per day?____________For how many years?_______________Have you tried to quit? Yes No14-27 Weeks:NoYes, how much per day?_____________Have you tried to quit? Yes No28-40 Weeks:NoYes, how much per day?_____________Have you tried to quit? Yes NoAre you often around other people who smoke cigarettes or any other tobacco products? YesNoDo you handle or have exposure to any of the following atExposure to chemicals, bacteria, viruses, and other substances can cause problems for the fetus, including birth defects, low birth weight, etc. Review appropriate steps for clients who work in at-risk settings. Notify the provider if client is exposed to a teratogenic or toxic substance, or if client is unmotivated to follow safety practices. Interventions:Refer to STT Health Education: Cautions While Pregnant, and Workplace SafetyNotify provider of any harmful exposure to chemicals at home or workReview and discuss STT Health Education handout: Pregnant? Steps for a Healthy Baby and Keep Safe at WorkRefer to MotherToBaby for information on medications, herbal products, infections, vaccines, maternal medical conditions, illicit substances, and other common exposures such as paint, pesticides, hot tubs, etc. The client or provider can call 1-866-626-6847 or visit: home, work, or doing any hobbies?0-13 Weeks14-27 Weeks28-40 WeeksProducts like bleach, ammonia or oven cleanersPesticides or chemicalsCooking with clay potteryJewelry makingGlue FertilizersCat litter boxPet turtles or reptilesRodentsDouchingHot baths or saunasX-RaysOther:______________NoneAt home, where do you store the following?:Vitamins ______________________________________Medications ___________________________________Cleaning Supplies _______________________________Are these things kept out of the reach of children?YesNoAll medications, even those considered “safe” like vitamins and iron, should be stored in a secure location, such as a locked cabinet. Cleaning products, perfumes, spices, and other potentially poisonous substances should be stored in their original containers, away from food and medicines, and secure from children (i.e., placed in high or locked cabinets). Interventions:Review and discuss STT Health Education handout: Keep Your New Baby SafeHave either of your parents had a drug or alcohol problem?Parental Drug/Alcohol Problem: Childhood abuse, neglect, and traumatic stressors such as parental drug/alcohol problems can increase the client’s risk for health and social problems. Additionally, women are more at risk for substance use/abuse if their mother has a history of alcohol/drug use. She may need referrals to support resources.Partner Drug/Alcohol Problem: Drug or alcohol abuse by a partner can be a risk factor for violence including domestic violence and/or intimate partner violence. If the client reports that her partner has a problem with drugs or alcohol, listen for information on how it affects their relationship. Additionally, women are more at risk for substance use/abuse if their partners use drugs and/or alcohol.Past Drug/Alcohol Problem: Women are more at risk to use alcohol and/or drugs during their pregnancy if they have a history of substance use or were frequent users before they became pregnant. There is no safe level of street drug or alcohol use for pregnant women. Alcohol is the leading cause of preventable birth defects. Encourage all pregnant women to avoid all drugs and alcohol. Any drug/alcohol consumption can put the mother and baby at risk for a miscarriage, complications with pregnancy, intrauterine death, premature birth, low birth weight, fetal alcohol syndrome, and other physical and mental disabilities. Interventions: Refer to STT Health Education: Drug and Alcohol Use and handout You Can Quit Using Drugs or AlcoholRefer to STT Psychosocial: Perinatal Substance Use/Abuse and handouts Your Baby Can’t Say “No,” and Drugs and Alcohol, When You Want to STOP UsingNotify provider immediately if patient responds yes to any of the questionsReferred to Alcoholics Anonymous (AA)Referred to Narcotics Anonymous (NA)Refer patient to local Medi-Cal Drug Treatment facilityRefer patient to social worker for additional counseling and referralsIf client considers one of her parents to be an addict or alcoholic, refer to Adult Children of Alcoholics, Al-Anon, or Alateen□No □Yes, describe:____________________Does your partner have a problem with drugs or alcohol?□No □Yes, describe:____________________Have you had a problem with drugs or alcohol in the past?□No □Yes, describe:____________________Have you used drugs or alcohol during this pregnancy? Drugswould include things like marijuana, heroin, cocaine, or ecstasy and alcohol would include things like beer, wine, or liquor.0-13 Weeks:NoYes, describe:____________________14-27 Weeks:NoYes, describe:____________________28-40 Weeks:NoYes, describe:____________________If you use drugs and/or alcohol, are you interested in quitting?0-13 Weeks:□ N/A□ Yes□ No14-27 Weeks:□ N/A□ Yes□ No28-40 Weeks:□ N/A□ Yes□ NoAre you taking a prenatal vitamin every day?It is possible for pregnant women to get most of the extra vitamins and minerals they need through a balanced diet, but because certain nutrients are still needed, all pregnant women should take a prenatal vitamin every day. Many women may also take herbal supplements that come from plants or plant parts. These products are often labeled “natural,” leading women to believe they are safe, which may not always be true. Inform the provider of any over the counter or herbal supplements the client is taking.Interventions:Confirm that provider has dispensed or prescribed prenatal vitamins if client does not already have a supplyEncourage client to continue taking prenatal vitamins (and any other supplements recommended by provider)Notify to the provider of any herbal remedies or medications the client is takingRefer to STT Nutrition: Prenatal Supplements: Vitamins, Minerals, and Other Supplements and handouts Take Prenatal Vitamins and Minerals, If You Need Iron Pills, and You May Need Extra CalciumRefer to MotherToBaby for information on medications, herbal products, infections, vaccines, maternal medical conditions, illicit substances, and other common exposures such as paint, pesticides, hot tubs, etc. The client or provider can call 1-866-626-6847 or visit: 0-13 Weeks:YesNo14-27 Weeks:YesNo28-40 Weeks:YesNoAre you taking any prescription, over-the-counter, or herbalmedications? Examples: iron, pain medication, antidepressants, antacids, allergy medication, laxatives, or herbal remedies like yerba buena, ginseng, or manzanilla?0-13 Weeks:NoYes:________________________14-27 Weeks:NoYes:________________________28-40 Weeks:NoYes:________________________Pregnancy CareBesides having a healthy baby, what are your goals for this pregnancy? _____________________________________The client may be able to use this opportunity to make personal changes in her life (e.g., stop smoking, finish school, etc.), rather than focusing on only one goal of “a healthy baby.” Provide resources and support as needed.Do you plan to have someone with you:If the client cannot identify a support person for labor, you should discuss possible resources, including childbirth classes. If she has no support in the immediate postpartum period, this is an opportunity to help the client talk about who will be available to help her care for herself, the newborn (including breastfeeding support), and other children, if any.Interventions: Refer to childbirth classesRefer to home visitation programDuring labor?14-27 Weeks:NoYes:_______________________28-40 Weeks:NoYes:_______________________When you first come home with the baby?14-27 Weeks:NoYes:_______________________28-40 Weeks:NoYes:_______________________If you had a baby before, where was it delivered?N/AClinicHospitalHomeOther:________________________________Did you or the baby have any problems? NoYes, explain:____________________________If the patient delivered at home or in a clinic, it may have been because of complications. Assist the client in making plans to avoid them with this pregnancy. Interventions:Notify provider if there were prior complicationsIf the client is delivering at a different hospital than before, offer her information about the delivery hospital, including tours, registration, parking, and how to get there from her homeHave you ever lost any children? (miscarriage, stillbirth, SIDS, immigration, custody, etc.)NoYes, please explain:_____________________________“Lost” children may include miscarriages, stillbirths, adoptions, abortions, SIDS (Sudden Infant Death Syndrome), children placed in foster care, etc. The client may have unresolved grief, guilt, depression, anxiety, or trauma that can impact her pregnancy and care of the newborn. Interventions:Refer to STT Psychosocial: Perinatal LossReview and discuss STT Psychosocial handouts: Loss of Your Baby and Ways to Remember Your BabyRefer her to a local grief and loss resources appropriate for her type of lossRefer to social worker or local mental health clinic if her mental symptoms affect her ability to take care of herself, family, or work functioningRefer to First Candle grief support line at: 1-800-221-7437Do you have any questions about any prenatal tests orAssess the client’s understanding of her current pregnancy health status, provide education about any tests, and answer her questions. Interventions:Refer to STT Appendix: Prenatal Laboratory and Diagnostic TestsAnswer questions and refer to provider as neededprocedures?0-13 Weeks:NoYes:________________________14-27 Weeks:NoYes:________________________28-40 Weeks:NoYes:________________________Have you experienced any of these discomforts during yourAll danger signs described for the client during CPSP Orientation must be reported to the health care provider immediately. Danger signs include: fever or chills, swollen face and/or hands, bleeding from the vagina, change in vision, difficulty breathing, severe headaches, sudden weight gain, accident with a hard fall or blow to the abdomen, cramps in the stomach or uterus, pain or burning with urination, sudden flow or leaking of fluid from the vagina, severe nausea/vomiting. See below for specific interventions for each condition.pregnancy?0-13 Weeks14-27 Weeks28-40WeeksEdema (Swelling in hands feet)DiarrheaConstipationNausea/VomitingLeg crampsHemorrhoidsHeartburnVaricose veinsHeadachesBackachesVaginal bleedingCramping or contractionsNoneEdemaEdema (swelling of the hands or feet): 60 to 80% of pregnant women will experience edema sometime during their pregnancy.Interventions:Notify provider if there is sudden weight gain or swelling of the faceCheck client’s blood pressure and notify provider if it is higher than normalAssess dietary intake for nutritional adequacy, especially proteinEncourage client to elevate her feet, avoid eating salty foods, and drink at least 8 glasses of water a dayDiarrhea:Diarrhea may be caused by a number of things, including lactose intolerance, food poisoning, or excessive iron. It is also common later in pregnancy or during early labor.Interventions: Notify health care provider immediately if diarrhea is accompanied by cramping or fever, if it has lasted for more than a few days, if it contains blood or mucus, or if she starts to get dehydratedIf client is lactose intolerant, refer to STT Nutrition: Lactose Intolerance. Review and discuss STT Nutrition handouts: Do You Have Trouble with Milk Foods? and Foods Rich in CalciumConstipationConstipation is a common discomfort in pregnancy. Many women may wish to use laxatives for the relief of constipation. Taking certain laxatives can be harmful to pregnant women and their babies. Interventions: Refer to STT Nutrition: ConstipationReview and discuss STT Nutrition handouts: Constipation: What You Can Do and Constipation: What Products You Can and Cannot UseNotify health care provider if the client also complains of back pain or has not had a bowel movement for more than several daysNausea/VomitingNausea and vomiting occurs in about half of all pregnancies, especially between the 2nd and 16th weeks gestation. These symptoms are usually worse in the morning, but can happen at any time. Nausea and vomiting can be caused by hormonal changes, psychological factors such as anxiety about the pregnancy, and poor diet habits. Hyperemesis gravidarum is a serious problem in pregnancy that involves uncontrolled, repeated episodes of vomiting. It can also cause rapid weight loss and other problems. Interventions:Notify health care provider if:Current weight loss is more than 5 lbs. below pre-pregnancy weight or more than 3 lbs. from her last visit If symptoms have worsened and vomiting is not controlled If there is no weight gain by 16 weeksIf she has dizziness, weakness, fainting or headaches that do not go awayIf vomiting lasts for 24 hours or it cannot be stopped except by not having any food and fluidsRefer to STT Nutrition: Nausea and Vomiting and STT Nutrition handouts: Nausea: Tips that Help, Nausea: What To Do When You Vomit, and Nausea: Choose These FoodsLeg CrampsLeg cramps may occur in some women during the second half of pregnancy. The cause of leg cramps during pregnancy is unknown, but good nutrition without excessive amounts of any nutrients is a good idea. Interventions:Encourage adequate calcium intake from foods such as milk and milk productsEncourage adequate magnesium intake from eating dark leafy green vegetables (spinach, kale or Swiss chard), beans, lentils, bananas, and whole grain breads and cerealsEncourage the client to stretch her legs (especially her calves) before going to bed to help reduce chances of getting leg cramps. Tell her to avoid pointing her toes when stretching or exercisingNotify health care provider if the pain is frequent and severe or if she has any redness, warmth, swelling or tenderness in her legHemorrhoidsHemorrhoids are caused by the pressure of the pregnant uterus interfering with circulation and are aggravated by constipation.Interventions:Instruct the client in the prevention and treatment of constipationDiscuss use of cold compresses with or without witch hazel or Epsom saltsTalk about careful hygiene - keeping the anal area clean helps prevent itching and burningDiscuss use of any topical medications with the health care provider before useNotify health care provider if there are symptoms unrelieved by cold compresses and/or witch hazel (witch hazel is inexpensive and available over-the-counter)HeartburnHeartburn (gastroesophageal reflux) is a burning pain that happens in the mid chest area when the opening to the stomach relaxes and food and acid comes back up from the stomach to the esophagus.Interventions:Refer to STT Nutrition: HeartburnReview and discuss STT Nutrition handouts: Heartburn: What You Can Do and Heartburn: Should You Use Antacids?Refer to the health care provider if heartburn continues or worsens, if weight gain is inadequate, or if the woman is taking large amounts of antacidsVaricose veinsVaricose veins may affect the legs, vulva, and pelvis. They can be caused by heredity, pressure of the pregnant uterus on the large veins of the pelvis, prolonged standing, or restrictive clothing.Interventions:Encourage client to avoid restrictive clothing, elevate legs and hips on pillows, use supportive stockings, and take frequent breaks to sit down if standing for long periods of timeRefer to the health care provider if varicose veins are causing pain or discomfortHeadachesSevere, persistent headache is a danger sign and must be reported to the health care provider immediately.Intervention:Occasional headaches may be relieved by relaxation techniques, massage, bath or shower, cool compress, and/or mild analgesics when recommended by the health care providerBackachesBackaches in pregnancy may be caused by normal strain on the back from carrying the extra weight of pregnancy. Backaches may also be a sign of preterm labor so it is important to remind all clients of the signs of preterm labor and the procedure to follow if they occur. Interventions:Refer to STT Health Education: Preterm Labor and STT Health Education handout: If Your Labor Starts Too EarlyRefer to STT Health Education: Safe Exercise and Lifting and handout: Exercises To Do When You Are PregnantVaginal bleedingVaginal bleeding is a danger sign in pregnancy and must be reported to the health care provider immediately.Interventions: Notify healthcare provider immediatelyRefer to STT Health Education: Preterm LaborReview and discuss STT Health Education handout: If Your Labor Starts Too EarlyAbdominal cramping/contractionsAbdominal cramping and/or contractions are danger signs in pregnancy and must be reported to the health care provider immediately.Interventions:Notify healthcare provider immediatelyRefer to STT Health Education: Preterm LaborReview and discuss STT Health Education handout: If Your Labor Starts Too EarlyDoes the doctor say there are any problems with thisThis question offers an opportunity to assess the client’s understanding of her current pregnancy health status and provide teaching, counseling and referrals. Interventions:Refer to the provider or health educator for complex medical or obstetrical problemsSee the STT Nutrition Introduction for a list of problems that may require referral to a registered dietitianDepending on the problem, refer to: STT Health Education - Preterm Labor, Kick Counts, Labor Induction, Multiple Births - Twins and MoreReview and discuss the appropriate STT Health Education handouts: If Your Labor Starts Too Early, Count Your Baby’s Kicks, What You Need to Know About Labor Induction, and Getting Ready for MultiplesRefer to Prenatal Diagnostic Center (PDC) as appropriatepregnancy?0-13 Weeks:NoYes:_______________________14-27 Weeks:NoYes:_______________________28-40 Weeks:NoYes:_______________________Compared to your previous pregnancies, is there anything you would like to change about the care you receive this time?N/A NoYes, explain:____________________Do not ask this question unless there have been previous pregnancies. The information the client shares can be an empowering way for her to ask for what she wants or doesn’t want during this pregnancy. Interventions: Notify provider of the client’s requests or concernsProvide information or referrals as appropriateWho has given you the most advice about your pregnancy?MotherGrandmotherPartnerMother-in-law FriendNo oneOther:____________________________________What are the most important things they have told you?Describe:_____________________________________This question will help identify who is involved in the client’s care. The client’s responses may reveal misinformation, cultural practices, and/or what type of social support she has. Interventions: Notify provider regarding any harmful adviceEncourage client to have support person participate in prenatal education/classesDo you have any traditions, customs or religious beliefs about pregnancy?□ No□ Yes: Please explain:_____________________________________________________________________If yes, Conflicts with medical recommendations?□ No □ Yes Acknowledging cultural and religious customs may increase the client’s participation in her pregnancy care. In some cases, the client’s customs may be in conflict with medical recommendations. It is important to take the time to evaluate these situations with the medical provider. Interventions:Refer to provider for discussion of any potentially harmful practicesRefer to STT First Steps: Cultural Considerations, Cross-Cultural Communication, and Clients with Alternative Health Care ExperiencesWould you like to become pregnant in the next 18 months?Unplanned pregnancies are known to have worse health outcomes for both the mother and the infant. Unplanned pregnancies can also lead to social problems such as increasing family stress, increasing the need for financial support programs, and increasing the risk for family violence. It is recommended for most women to space their pregnancies at least 18 months to ensure that their pregnancy is wanted, planned, and as healthy as possible.Interventions:Emphasize the importance of waiting 18 months between pregnancies.Review and discuss STT Health Education: Family Planning ChoicesRefer to the provider to discuss the effectiveness of her chosen birth control method and the different options available based on plans for spacing future pregnanciesIf the client reports that her partner pressures her to become pregnant or interferes with her birth control, encourage client to talk to an OB or family planning provider about birth control methods that are less detectable (such as a shot, implant, or an IUD with the strings trimmed)Birth control methods with estrogen may interfere with breastmilk production. Refer to provider for further discussion of options that do not interfere with breastfeedingMedi-Cal clients who request sterilization have a mandatory 30-day waiting period after signing the informed consent form14-27 Weeks:YesNo28-40 Weeks:YesNoHas your partner ever pressured you to become pregnant, interfered with your birth control, or refused to wear a condom?□ Never □ Sometimes □ OftenDo you plan to use birth control after this pregnancy? 14-27 Weeks:NoUndecidedIf yes, what method(s):28-40 Weeks:NoUndecidedIf yes, what method(s):Most effective methods (when used correctly)IUDVasectomyPatchImplantInjection/shot RingTubal ligationPillsLess effective methods (higher failure rate)CondomsDiaphragm AbstinenceSpermicidesCervical capWithdrawalFertility awareness methodsOther:____________________________________These questions help us identify any risk factors for diseases like chlamydia, gonorrhea, herpes, hepatitis C, or HIV:Have you or your partner recently had sex with anybody else? □ Yes□ Unsure□ NoHave you or any partners ever had an STD? □ Yes□ Unsure□ NoHave you ever had sex while using alcohol or drugs? □ Yes□ Unsure□ NoHave you or any partners exchanged sex for drugs, money, or shelter? □ Yes□ Unsure□ NoHave you or any partners ever shared needles? □ Yes□ Unsure□ NoThe client should, if possible, be alone when asked these questions. Whether or not she has a sexually transmitted infection (STI), it is important for every client to know how to protect herself and her baby. Research shows that pregnant women are more likely to become infected with STDs - possibly because they no longer think they need to use condoms if their primary purpose is viewed as the prevention of pregnancy.Interventions:Notify the provider of any risky sexual behaviors or symptoms of STIsRefer to STT Health Education: STIs (Sexually Transmitted Infections) and HIV and PregnancyReview and discuss STT Health Education: What You Should Know About STDs, What You Should Know About HIV, and You Can Protect Yourself and Your Baby from STDsRefer to Los Angeles County STD Program Hotline for more information and referrals to STD clinics and HIV test sites in Los Angeles County at: 1-800-758-0880 (English & Spanish)Refer to local confidential/anonymous STD testing locations in your areaAny change in HIV/STI risk status?14-27 Weeks:YesNo28-40 Weeks:YesNo Educational InterestsHow do you like to learn new things?Text messages/appsOne-on-one educationReading/handoutsVideosGroup classesOther:______________Tailor your health education services to her preferred learning style such as using more written materials if she prefers those.Interventions:Refer clients who prefer text messaging to Text4Baby by texting BABY (or BEBE for Spanish) to 511411Provide education in client’s preferred learning methodsWill someone be able to attend prenatal classes with you?NoUnsureYes, who? _____________________The client’s response may give you information about her support system. Interventions: Encourage the client to share prenatal education materials with a support person like the father of the baby, friend, parent, or close relativeDo you have any physical, mental, or emotional conditions, such as learning disabilities, Attention-Deficit/Hyperactivity Disorder, depression, hearing or vision problems that may affect the way you learn?NoYes:________________________If her disability, such as vision, has been corrected so that it doesn’t interfere with her learning, you don’t need to check ‘Yes’. If the client has learning disabilities, she may learn better in individual or small group health education appointments instead of large classes. She may also find it helpful to have a partner or family member present during health education. Interventions: Contact the client’s health plan or visit Medi-Cal’s website for more information about hearing and/or vision services and eligibilityClients with developmental disabilities or other learning challenges may need to be referred to a health educator for more support and educationDo you have experience with pregnancy, prenatal care, labor & delivery, postpartum self-care, and infant care & safety?YesNoNew moms may need extra education and support to learn about pregnancy, prenatal care, labor & delivery, postpartum self-care, and infant care & safety. Home visitation programs for new moms can be a great support, especially when she has additional risk factors or her support system is limited. Interventions: Sign up for Text4Baby by texting BABY or (BEBE for Spanish) to 511411Review/discuss STT HE handouts: Pregnant? Steps for a Healthy Baby and Keep Your New Baby Safe and HealthyRefer to home visitation programRefer to group education classesWould you like information about the following topics?0-13Weeks14 -27Weeks28 – 40WeeksProvide information on perinatal topics based on the client’s requests.Interventions: Document the date the education was provided and specify the teaching methodHow your baby grows (fetal development)How your body changes during pregnancyHabits for a healthy pregnancy/babyWhat happens during labor/deliveryPreparing for the delivery hospitalHelping your child(ren) get ready for a new babyHow to take care of yourself after the baby comesBreastfeedingHow to take care of your baby (infant health & safety)Infant developmentCircumcisionImmunizations needed during pregnancy (flu and Tdap)Birth control methodsDo you plan on receiving Tdap vaccine in your 3rd trimester?Pertussis (also called whooping cough) is a highly contagious disease that can cause babies to have coughing fits, gasp for air, and turn blue from lack of oxygen. In newborns, pertussis can be a life-threatening illness. When a woman gets the whooping cough vaccine (also called Tdap) during her 3rd trimester, she will pass antibodies to her baby. This will help keep the baby protected during their first few months of life, when they are most vulnerable to Pertussis and its complications. Tdap should be given for each pregnancy, regardless of the client’s vaccination history. Interventions:14-26 weeksProvide education on the benefits of getting Tdap between 27-36 weeks in the 3rd trimesterAfter 27 weeksProvide additional education on the benefits of getting Tdap between 27-36 weeks in the 3rd trimesterProvide a referral for the Tdap vaccineAdminister Tdap to clientIf client declines Tdap during pregnancy, discuss client receiving Tdap after deliveryDocument if client declines Tdap 14-27 Weeks: □ Yes □ No □ Unsure28-40 Weeks: □ Yes □ No □ UnsureIs there anything else that you would like to learn? ______________________________________________ ______________________________________________Provide any additional health education based on the client’s requests. Interventions:Document any additional education providedNutrition: AnthropometricWeight gain in last pregnancy: ___________________ lbs. □ Unknown □ N/APre-pregnant weight: _____________ lbs.Height: _______________________Recommended weight gain goal for this pregnancy:Single PregnancyUnderweight: 28-40 lbsNormal weight: 25-35 lbsOverweight: 15-25 lbsObese: 11-20 lbsTwin PregnancyNormal: 37-54 lbsOverweight: 31-50 lbsObese: 25-42 lbsAsking a woman about her weight gain during her last pregnancy can give you an idea about her possible weight gain pattern for this pregnancy. If she gained too little or too much weight in her last pregnancy, you can take the opportunity to provide education to assist her in having a healthier weight gain pattern for this pregnancy. All women should gain weight during pregnancy. An appropriate weight gain goal is determined by her height and pre-pregnant weight, and whether it is a single or twin pregnancy. Women who are overweight or underweight may need more comprehensive nutrition care.Interventions:Refer to STT Nutrition: Weight Gain During Pregnancy- Section: “How to Determine Gestational Weight Gain Goals and Assess Weight Gain”Underweight:Refer to STT Nutrition: Weight Gain During Pregnancy – Section: “Underweight”Review and discuss STT Nutrition handouts: MyPlate for Moms and Tips to Gain WeightRecommend regular meals and larger portionsDiscuss weight gain goal per month = 3-4 lbs for single pregnancyOverweight:Refer to STT Nutrition: Weight Gain During Pregnancy – Section: “Overweight”Review and discuss STT Nutrition handout: MyPlate for MomsRecommend smaller portions, more fruits and vegetables, and low/nonfat foodsDiscuss weight gain goal per month = 2-3 lbs after 16th week for single pregnancyObese:Refer to STT Nutrition: Weight Gain During Pregnancy – Section: “ Obese” Review and discuss STT Nutrition handout: MyPlate for MomsRecommend smaller portions, more fruits and vegetables, and low/nonfat foodsDiscuss weight gain goal per month = 2.5 lbs after 16th week for single pregnancyNet Weight GainIn pregnancy, the total amount gained and rate of weight gain are important for good health. Net weight gain is based on pre-pregnant weight. Some clients, including many teen girls, may limit their food intake in order to stay slim and/or hide their pregnancy. Encourage healthy eating habits and make appropriate referrals, since poor eating habits can lead to health problems for her and baby. Interventions:Refer to STT Nutrition: Weight Gain During Pregnancy to determine client’s recommended net weight gainProvide information to the client about any age-related nutritional needs (i.e., extra iron/calcium) Give referral to registered dietitian if:Weight loss of 5 or more lbs in the first 12 weeks of gestationMore than 5 lbs below reported pre-pregnant weightWeight loss of 3 or more lbs since the last visitEating disorders are found or if she is choosing not to eat enough foodExcessive Weight Gain:Discuss risk of larger baby and delivery complicationsReview and discuss STT Nutrition handout: Tips to Slow Weight GainRecommend low fat foods, more water, and less sugary drinks like soda and juiceInadequate Weight Gain:Discuss risk of preterm/low birth weight babyReview and discuss STT Nutrition handout: Tips to Gain WeightRecommend more frequent, calorie-dense mealsWeight Loss:Notify providerDiscuss risk of preterm/low birth weight babyReview and discuss STT Nutrition handout: Tips to Gain WeightRecommend more frequent, calorie-dense meals0-13 Weeks: _____________lbs. AdequateExcessiveInadequateWeight Loss14-27 Weeks: _____________lbs.AdequateExcessiveInadequateWeight Loss28-40 Weeks: _____________lbs.AdequateExcessiveInadequateWeight LossNutrition: Biochemical Consult with provider if there are abnormal lab values and These tests can tell the medical provider if the client is anemic or diabetic. Anemia means she does not have enough iron in her red blood cells. Lack of iron can restrict the amount of oxygen that gets to her cells. Anemia increases the risk for preterm birth, low birth weight, and other medical problems. Abnormal glucose values may indicate the need for further screening for Gestational Diabetes Mellitus (GDM).Screening for GDM: Oral Glucose Tolerance Test (OGTT)ACOG recommends that women with any of the following risk factors be tested for GDM at their first prenatal visit:Increased weight (i.e., BMI greater than 25)Decreased physical activityFirst degree relative with diabetesMember of ethnic group with high prevalence of diabetes (African American, Latino, American Indian, Asian American, Pacific Islander)Prior history of GDM or delivery of a baby greater than 9 lbsMetabolic abnormalities (hypertension, HDL <35mg/dL, triglyceride level >250mg/dLPolycystic ovarian syndromeHbA1C 5.7% or higherImpaired glucose tolerance or impaired fasting glucose testing in the pastEvidence of insulin resistance (acanthosis or severe obesity)History of cardiovascular disease Women with no known history or risk factors should be tested between 24-28 weeks.Diagnostic blood glucose values (with a 75gm, 2 hour OGTT): Fasting: > 92 mg/dL1 hour: ?> 180 mg/dL2 hours: > 153 mg/dLOne abnormal value is diagnostic of GDMInterventions: Notify provider of any abnormal lab valuesTest results of less than 11gms for hemoglobin or less than 33% for hematocrit may indicate anemia; however, variations in these values can also be related to normal pregnancy changesClients whose results indicate anemia should be encouraged to eat foods high in iron and vitamin CRefer to interventions in question 68 if she has iron deficiency anemiaRefer to interventions in question 69 if she has GDMdiscuss treatment prescribed.0-13 Weeks: Date blood drawn: _______________ Hgb: __________ (<11g/L) Hct: __________ (<33%) Glucose: __________MCV: __________14-27 Weeks: Date blood drawn: _______________ Hgb: ________ (<10.5 g/L) Hct: __________ (<32%) Glucose: __________MCV: __________28-40 Weeks: Date blood drawn: _______________ Hgb: __________ (<11 g/L) Hct: __________ (<33%) Glucose: __________MCV: ________23552141720 OGTT Initial Prenatal Visit (if applicable)Date:_________Fasting: _______ 1 Hr: ______ 2 Hr: ______ □ N/A 24-28 weeks:Date :_________Fasting: _______ 1 Hr: ______ 2 Hr: ______ Nutrition: ClinicalCurrent serious infections? (Ex: Kidney infection, HIV, TB, etc.)Nutritional needs increase with serious infections due to problems with digestion and absorption of foods and increased need for nutrients to help repair body tissues.Interventions: Refer to dietitian and/or medical/OB provider for HIV, hepatitis, tuberculosis, kidney infection, or any other type of infection0-13 Weeks:NoYes:_______________________14-27 Weeks:NoYes:_______________________28-40 Weeks:NoYes:_______________________AnemiaAnemia occurs when there is a problem with the red blood cells. This can cause a lack of enough oxygen getting to the cells and organs in the body. Iron-deficiency anemia - the most common form of anemia (low hemoglobin and hematocrit levels in the blood)Folic acid deficiency anemia - high MCV value (>95)Vitamin B12 anemia - the least common form of anemia, but can occur if the client is a strict vegetarian who eats no animal proteins (also known as a vegan diet)Interventions:Refer to STT Nutrition: Iron Deficiency and Other AnemiasRefer to registered dietitian and/or medical/OB provider if:- Anemia has not improved within 1 month of the start of treatment- Client has a history of Sickle Cell disease or other medical disorders known to cause anemia- Client is unable or unwilling to take iron supplements due to discomforts- Vegan food practices with limited food choicesIron-deficiency anemiaProvide client with a copy of STT Nutrition handouts: Get the Iron You Need, Iron Tips, Iron Tips – Take Two!, and My Action Plan for IronFolic Acid Deficiency AnemiaReview and discuss STT Nutrition handouts: Get the Folic Acid You Need and Folic Acid: Every Woman, Every DayVitamin B12 Deficiency AnemiaRefer to STT Nutrition: Vegetarian EatingReview and discuss STT Nutrition handouts: When You Are Vegetarian: What You Need to KnowReview and discuss STT Nutrition handout: Vitamin B12 is ImportantRefer to provider to discuss Vitamin B12 injections 0-13 Weeks:NoYes:_______________________14-27 Weeks:NoYes:_______________________28-40 Weeks:NoYes:_______________________DiabetesHaving diabetes either as a pre-pregnancy condition or a condition that develops during pregnancy increases the risk for birth defects and for having a big (large for gestational age) baby.Interventions: If client had diabetes in past pregnancy and was told that her diabetes went away after delivery (gestational diabetes mellitus - GDM), stress the importance of keeping all prenatal appointments and labs, as well as maintain a healthy diet and moderate exercise. Women with GDM are at increased risk for developing Type 2 diabetes later in life. Review and discuss STT Gestational Diabetes: Gestational Diabetes Mellitus (GDM) Review and discuss STT Gestational Diabetes handouts: MyPlate for Moms for Gestational Diabetes, If You Have Diabetes While You Are Pregnant: Questions You May Have, and If You Have Diabetes While You Are Pregnant: Ways to Lower Your StressRefer to a diabetes specialist or California Diabetes and Pregnancy Program (CDAPP) Sweet Success AffiliateRefer to registered dietitian Pre-pregnancy:NoYes Past pregnancy:NoYes Current pregnancy: 0-13 Weeks:NoYes 14-27 Weeks:NoYes 28-40 Weeks:NoYesHypertensionHypertension is another name for high blood pressure. Chronic (ongoing) hypertension may affect the baby’s growth. The use of certain hypertension medications may interfere with the digestion and absorption of certain nutrients, and may not be safe during pregnancy. Hypertension can also increase the risk of heart disease.Interventions: Stress the importance of keeping all health care provider appointments for any existing medical/OB problems.Review and discuss STT Health Education handout: Signs and Symptoms of Heart Disease During Pregnancy and PostpartumRefer to registered dietitian and/or medical/obstetrical provider if hypertension exists in current pregnancy. The provider should discuss treatment options, including medication, and should discuss whether exercise is safe or notRefer to MotherToBaby for information on medications, herbal products, infections, vaccines, maternal medical conditions, illicit substances, and other common exposures such as paint, pesticides, hot tubs, etc. The client or provider can call 1-866-626-6847 or visit: Pre-pregnancy:NoYesPast pregnancy:NoYesCurrent pregnancy:0-13 Weeks:NoYes14-27 Weeks:NoYes28-40 Weeks:NoYesHistory of poor pregnancy outcome (low birth weight, preterm labor/delivery, large for gest. age)NoYes: _________________________________ Other medical/OB problems? (Ex: thyroid, cancer, lupus, etc.)0-13 Weeks:NoYes:______________________14-27 Weeks:NoYes:______________________28-40 Weeks:NoYes:______________________Pregnancy interval < 18 months? □ Yes □ NoHigh parity? (≥ 4 births) □ Yes □ NoThese conditions put the client at risk for low birth weight babies, preterm delivery, and prenatal morbidity and mortality due to a decreased nutritional status. Interventions:Discuss the importance of a healthy diet to get the nutrients and calories she needsDiscuss the importance of taking prenatal vitamins every day Discuss with the client her increased risk status and the pregnancy interval recommended by her healthcare providerMultiple gestation? □ Yes □ NoNutritional needs and weight gain goals will change if the client is carrying more than one baby. Multiple gestation also puts the client at an increased risk for preterm labor. Use the appropriate weight gain grid for twins. Just like with a single pregnancy, the amount of weight a woman should gain depends on her pre-pregnancy weight. Weight CategorySingleTwinsUnderweight28-40 lbs.N/ANormal25-35 lbs.37-54 lbs.Overweight15-25 lbs.31-50 lbs.Obese11-20 lbs.25-42 lbs.Interventions:Refer to STT Health Education: Multiple Births—Twins and MoreReview & discuss STT Health Education handouts: Getting Ready for Multiples and Baby Products: Discounts and CouponsReview & discuss STT Health Education handout: If Your Labor Starts Too Early. Encourage her to call immediately if she experiences those warning signsRefer to registered dietitian for regular nutrition assessments and counselingAre you currently breastfeeding? □ Yes □ NoBreastfeeding while pregnant is safe for most women, but extra calories and nutrients are needed for both breastfeeding and for the pregnancy itself. The client will need to make sure she is getting enough calories and nutrients in her diet to gain an appropriate amount of weight each month. Interventions:Refer to provider if the client has a history of miscarriage or preterm labor and she is currently breastfeeding while pregnant Discuss the importance of adequate food intake and meeting her weight gain goals each monthGive referral to registered dietitian if client wishes to keep breastfeeding, but is not gaining enough weightNutrition: DietaryHave your eating habits changed since you’ve been Pregnant women should strive to eat balanced, regular meals of the recommended amount from each food group. Women may experience cravings from time to time, but binge eating or skipping meals can be harmful to mom and baby.Interventions:Review client’s pregnancy weight, BMI, and weight gain goal for each month. Check to see if she’s meeting her weight gain goal according to her BMIIf the client is not gaining enough weight or is eating less of any core nutrient, review & discuss STT Nutrition handout: MyPlate for Moms, highlighting the food groups she’s lacking and proper portion sizesIf the client is gaining too much weight or is eating too much of any core nutrient (especially fats & sweets), review & discuss STT Nutrition handout: MyPlate for Moms, highlighting more nutritious food groups and proper portion sizes pregnant?0-13 Weeks:□ No□ Yes:________________________14-27 Weeks:□ No□ Yes:________________________28-40 Weeks:□ No□ Yes:________________________Do you ever crave/eat any of the following:Yes: Ice, freezer frost, corn starch, dirt, paint chips, plaster, clay, pottery, paste, other:_________________NoPica is the craving for nonfood items. Excessive intake of these nonfood items may take the place of nutritious foods in the diet and can interfere with the body’s absorption of iron. Some of these nonfoods may include items with lead and be toxic. Interventions:Refer to STT Nutrition: PicaReview STT Nutrition handout: MyPlate for Moms with the client to help reinforce what the client needs to eat for a healthy pregnancyRefer to provider and/or registered dietitian to assess for potential medical problems, determine if the item contains toxic substances, or could result in medical or nutrition problemsNumber of meals/day:______________Meals often skipped? YesNoNumber of snacks/day:__________________Eating fewer than 3 meals a day and/or skipping meals may result in a diet that is inadequate for pregnancy. If the client often skips meals, this may indicate a more serious problem.Interventions: Review STT Nutrition handout: MyPlate for Moms and discuss the amount of food she needs for a healthy pregnancyTalk about the importance of eating foods from all of the different food groups, and the need to eat meals and snacks at regular times throughout the dayEncourage the client to carry small snacks if she will be out, and to try to eat every 4-6 hoursIf her diet assessment indicates that she is low in several food groups and/or the client skips meals on a regular basis, this may indicate a greater problem and/or an eating disorder, and increases the risk for poor nutrition. Refer to CPSP provider and/or registered dietitian Who does the following in your home?Buys food:___________________Cooks/prepares food:___________Food choices and availability may be limited if the client has little control over what foods are purchased and/or how these foods are prepared. If she is the one who cooks, she will need to know how to safely store and prepare food to prevent food-borne illnesses. Interventions:Refer to STT Nutrition: Getting Healthy FoodsReview and discuss STT Nutrition handouts: Tips for Healthy Food Shopping, You Can Buy Healthy Food on a Budget, and You Can Stretch Your Dollars: Choose These Easy MealsRefer to STT Nutrition: Cooking & Food Storage and Food Safety Review and discuss STT Nutrition handouts: Tips for Cooking and Storing Food, Don’t Get Sick From the Foods You Eat, Eat Fish Safely – Tips, Checklist for Food Safety, Lower Your Chances of Eating Food with Unsafe Chemicals in Them, and Tips for Keeping Foods Safe Are you on any special diet (medical diet, personal diet, etc.)?Sometimes clients are placed on diets by a healthcare professional for medical reasons (i.e., diabetic diet, low salt diet, gluten-free diet, etc.). Other times clients go on diets for personal reasons, including weight loss. It is important to ask the client to describe what specific diet she is on and why.Interventions:If client is on a weight loss diet, stress that pregnancy is not the time to lose weight, but to gain it. Weight loss interferes with the needs of the growing baby. Refer to STT Nutrition: Weight Gain During Pregnancy and discuss her specific weight gain goals based on her pre-pregnancy weight categoryReview & discuss STT Nutrition handout: MyPlate for Moms and emphasize serving sizes recommended for pregnancyRefer to registered dietitian and/or medical/obstetrical provider for conditions requiring medical nutrition therapy such as diabetes, liver disease, renal disease, cancer, and GI disturbances that exist in current pregnancy0-13 Weeks:Yes, explain:_________________________No14-27 weeks:Yes, explain:_________________________No28-40 weeks:Yes, explain:_________________________NoAny food allergies?□ No □ Yes:_______________ Any foods/beverages you avoid?□ No □ Yes:_______________ Food allergies are not the same as food intolerance. Food allergies can cause mild or more severe symptoms such as hives, swelling, difficulty breathing, vomiting and can be life threatening. Food intolerance may cause gas, cramps, diarrhea, headaches, and heartburn, but are not considered life threatening. Foods or beverages may be avoided for religious, cultural, ethnic or personal preference reasons. Avoiding foods/beverages is a problem if it interferes with the client’s nutritional status. Interventions: Clients should never be advised to eat foods to which they are allergicRefer to STT Nutrition: Lactose Intolerance and review STT Nutrition handouts: Do You Have Trouble with Milk Foods? and Foods Rich in CalciumRefer to health care provider and/or registered dietitian if she has allergies that lead to a poor diet or if her calcium intake remains low despite educationAre you vegetarian or vegan?NoYes: Do you eat:Milk ProductsEggsNutsBeans Chicken/FishMost vegetarian diets can provide adequate nutrition for pregnant and breastfeeding women. Vegans (people who do not eat any animal products, including dairy or eggs) are at risk for Vitamin B12 deficiency anemia if they do not supplement their diet. Interventions: Notify provider if client is VeganRefer to STT Nutrition: Vegetarian Eating and review STT Nutrition handout: When You Are a Vegetarian: What You Need to Know and Vitamin B12 is ImportantRefer to registered dietitian and/or medical/obstetrical provider if the client is vegan, has anemia that has not improved within 1 month after the start of treatment, or is unwilling to accommodate pregnancy nutrient requirements into daily intakeBreastfeeding is the normal food for infants. Doctors recommend that women feed their babies nothing but breastmilk for the first six months and continue breastfeeding through the first year with additional foods. Your role is to assess breastfeeding desires and barriers, to listen to her choices and concerns, and to offer correct information, support, and referrals. Even if the woman plans to formula feed, offer education that breastfeeding is the normal feeding choice and provide more information as needed.Interventions:0-13 WeeksIf a mother wants to use formula (exclusively or in addition to breastfeeding), explore her reasons and provide information about the risks of formula feeding or combo feeding so that she can make an informed decisionRefer to STT Nutrition: Breastfeeding and Tips for Addressing Breastfeeding Concerns and My Birth Plan. Review and discuss WIC handout (available online): How Does Formula Compare to Breastmilk?Refer to WIC and/or breastfeeding education classes0-13 weeks:How do you plan to feed your baby? BreastfeedFormulaBreastfeed + FormulaUndecidedHave you ever breastfed or tried to breastfeed?If yes, for how long?_________________________ NoN/ADid you breastfeed for as long as you wanted?YesNo, explain:_______________________________N/A14-27 weeks:What do you think about breastfeeding your new baby? Not interestedThinking about itWants to Definitely willOther: ____________________________________ What questions do you have about feeding your baby? ___________________________________________14-27 WeeksIf the client is not interested or is undecided about breastfeeding, explore her questions and concernsRefer to STT Nutrition: Breastfeeding and Tips for Addressing Breastfeeding ConcernsReview and discuss STT Nutrition handout: My Birth Plan and My Action Plan for Breastfeeding Refer to WIC and/or breastfeeding education classes28-40 weeks:How do you plan to feed your baby during the first month?BreastfeedFormula Breastfeed + FormulaIf you are going to breastfeed, who can you go to for breastfeeding help? ____________________________What questions do you have about feeding your baby?____________________________________________28-40 WeeksIf client is planning to breastfeed, refer to STT Nutrition: Breastfeeding, Tips for Addressing Breastfeeding Concerns, and What to Expect While Breastfeeding: Birth to Six Weeks. Review and discuss STT Nutrition handouts: My Action Plan for Breastfeeding, My Birth Plan, and Nutrition and Breastfeeding: Common Questions and AnswersIf client is planning to formula feed, discuss formula preparation including proper hygiene, measuring, mixing, and storage. Discuss how she should always hold her baby while formula feeding and never prop the bottleIf the client is planning to both breastfeed and formula feed her baby, discuss how supplementing with formula (especially during the first month) prevents the baby from telling her body to make more milk and she may have some problems, including low milk supply, engorgement, or plugged milk ducts. The baby may also have a harder time latching onto the breast after receiving a bottleRefer to WIC and/or breastfeeding education classesDietary intake assessment completed:Interview the patient and complete a dietary intake assessment. If the client is not eating the recommended servings of 2 or more food groups, then her diet is considered inadequate. The client is high risk nutritionally if she is lacking the minimum number of servings from 2 or more food groups after nutrition education has been offered and diet reassessment has been completed at her next visit.Interventions: If the client’s diet is inadequate, or if she needs education about meeting the guidelines of a particular food group, review & discuss STT Nutrition handout: MyPlate for Moms and My Nutrition Plan for Moms, highlighting the food groups she’s lacking and proper portion sizesRefer to CalFreshRefer to WICRefer to foodbankRefer to a registered dietitian if client is lacking the minimum number of servings from 2 or more food groups after nutrition education has been offered and diet reassessment has been completed, and notify provider0-13 weeks:Perinatal Food Group Recall (PFGR) 24-hour Perinatal Dietary Recall Perinatal Food Frequency Questionnaire (PFFQ)Diet adequate as assessed?: Yes No14-27 weeks:Perinatal Food Group Recall (PFGR)24-hour Perinatal Dietary RecallPerinatal Food Frequency Questionnaire (PFFQ)Diet adequate as assessed?: Yes No28-40 weeks:Perinatal Food Group Recall (PFGR)24-hour Perinatal Dietary RecallPerinatal Food Frequency Questionnaire (PFFQ)Diet adequate as assessed?: Yes NoCoping Skills Are you currently having problems/concerns withany of the following?If she responds yes to any of the problems or concerns listed, reassure the client that all information will be kept confidential and used only to help connect her to appropriate resources and referrals. Interventions:Depending on her needs, refer to Steps to Take Psychosocial: Financial Concerns, Legal/Advocacy Concerns, New Immigrant, and Emotional or Mental Health ConcernsRefer to legal assistance (free or low-cost)Refer to home visitation program for additional supportRefer to provider or social worker for further evaluation and follow-up0-13 Weeks14-27 Weeks28-40 WeeksDivorce/separationRecent deathIllness (cancer, abnormal Pap smear, etc.)UnemploymentImmigrationLegalProbation/paroleChild Protective Services/DCFSOther:_______________NoneWhat things in your life do you feel good about?______________________________________________What things in your life would you like to change?______________________________________________Who do you turn to for emotional support?FOB/partnerFamily memberFriendOther:________________________________What do you do when you are upset?______________________________________________What do you do when you and your partner have disagreements?________________________________________________These questions provide information about the client’s strengths, her hopes, her support system, and her coping skills. Reinforce all strengths and positive responses.Interventions: Provide referrals as appropriateRefer to provider or social worker if her comments raise concern, indicate a danger to herself or others, or need additional assessment and follow-up Patient Health Questionnaire 9 (PHQ-9)The PHQ-9 is a validated nine-item tool used specifically for depression screening. Maternal depression is the leading complication of pregnancy and childbirth, striking at least?one in six?new mothers in Los Angeles County. Untreated depression can lead to bigger problems for the mother and baby if not identified and treated early. Interventions:For PHQ-9 scores of 5-9 (Mild)Refer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionReview and discuss STT Psychosocial handout: How Bad Are Your Blues?Review/provide the “Speak Up When You’re Down” brochure by Maternal Mental Health Now/LA County Perinatal Mental Health Task ForceAdvise client to inform the provider if symptoms worsenRefer to Postpartum Support International at: 1-800-944-4773Provide referral to mental health clinic or social worker which client can use for extra support or if symptoms worsenFor PHQ-9 scores of 10 or higher (Moderate-Severe)Notify the providerRefer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionReview and discuss STT Psychosocial handout: How Bad Are Your Blues?Review/provide the “Speak Up When You’re Down” brochure by Maternal Mental Health Now/LA County Perinatal Mental Health Task ForceRefer to Postpartum Support International at: 1-800-944-4773Refer to home visitation program for additional supportRefer to your mental health clinic or social worker for further evaluation, treatment, and supportCall the Los Angeles County Department of Mental Health Access Line at: 1-800-854-7771 for additional referrals, support, or psychiatric mobile response servicesRefer to mental health urgent care clinicIf the client is a danger to herself or others, immediately call 911or your local law enforcement agencyTotal Score: 0-4 (None – Minimal)5-9 (Mild)10-14 (Moderate)15-19 (Moderate Severe)20-27 (Severe) Are you currently receiving services from a local agency such as case management, home visiting, counseling, etc.?NoYes, please explain:_____________________Work with other agencies as much as possible (with the client’s signed consent) to provide and coordinate services. For example, your client may have a case manager with a program such as the Adolescent Family Life Program. With permission, you can consult with her case manager about what resources the client has been referred to. You can also work with the case manager to problem solve if there are any barriers to the client accessing services or attending appointments. In order to consult with other agencies, you will need the client to sign an authorization to release information form. The client has the right to decline signing the release form and the right to decline case coordination with other agencies. Interventions:Obtain client’s consent to contact agency to coordinate services by having client sign an authorization to release information formHave you ever attended individual or group counseling or therapy?NoIf Yes, when and why? __________________Have you ever been prescribed medications for emotional problems (sadness, anger, nervousness, irritability, difficulty sleeping, etc.)?NoIf Yes, what medication? ________________Have you ever been hospitalized for emotional problems or thinking about hurting yourself, etc.?NoIf Yes, when and why? __________________This information tells you about the client’s history of mental illness. If a client has a history of emotional problems or suicidal thoughts/attempts, these symptoms could reemerge during pregnancy and/or postpartum. Listen carefully for information the client may have had emotional problems in the past. She may need to be evaluated by a social worker or other mental health professional or be provided additional support during pregnancy/postpartum. Interventions:Refer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionIf the client has a past history of serious depression, mental illness, or attempted suicides, the provider should be notified and an appropriate referral made to the social worker or local mental health clinic for further assessmentRefer to home visitation program for additional supportHave you ever been emotionally or physically abused by your partner or someone important to you?NoYes, please explain:___________________ Do you ever feel afraid of your partner?NoYes, please explain:__________________Within the last year have you been hit, slapped, kicked, or otherwise physically hurt by someone?NoYes, by whom? ___________________How many times:__________________ Inform the client that because of your concern for her health and an increased risk for violence and abuse during pregnancy, you ask everyone questions about violence in the home. It is recommended, but not required, that you also tell the client that you must report the abuse if (1) she has current physical injuries from abuse, or (2) she is under the age of 18.If the client reports no abuse, tell her that if the situation changes, she should discuss it with her health care provider or CPHW. Many women will not admit abuse initially, but may discuss it later in the pregnancy when she feels safer and more trusting of her health care providers. Do not pressure the woman to respond to the abuse questions, even when there is evidence that she is not being honest.Interventions if she reports abuse (with or without injuries):Inform the client of your mandated reporting requirement if (1) she has current/physical injuries from abuse, or (2) she is under the age of 18Notify providerRefer to STT Psychosocial: Spousal/Intimate Partner Abuse Review and discuss STT Psychosocial handout: Cycle of Violence and Safety When Preparing to LeaveIf the client is under age 18, refer to STT Psychosocial: Child Abuse and Neglect and follow the mandated child abuse reporting procedure below on pages 43-45Refer to the LA County Domestic Violence Hotline at 1-800-978-3600 or the National Domestic Violence Hotline at: 1-800-799-7233. Contact for additional guidance and referralsRefer to a domestic violence shelter in your area for assistance with legal matters, housing for the client and any other questionsIf client reports stalking or threats (with no evidence or report of physical abuse), encourage her to go to the law enforcement agency in the area where this stalking took place. Her statements will be documented and law enforcement will determine if a crime took place and should be further investigatedRefer to STT Health Education: Family Planning ChoicesRefer to family planning providerRefer to health educatorRefer to social workerInterventions if she reports abuse AND has injuries:Inform the client of your mandated reporting requirement if (1) she has current/physical injuries from abuse, or (2) she is under the age of 18STOP the assessment and consult with the provider for help with this section. Refer to the clinic’s mandated reporting protocol on pages 43-45The provider should complete the Danger Assessment form (see Appendix) and document physical injuries on the body mapCall your local law enforcement agency immediately. They can offer her an Emergency Protective Order (EPO), which is an immediate, temporary restraining order so that she can be protected from battererWithin 48 hours of making this phone call, you are required to submit OCJP 920: Suspicious Injury Report Form (see Appendix) and send to your local law enforcement agencyIn the report, include any special instructions for safely contacting the client, and mention special needs (such as what language she speaks)Advocate for the client’s rights and needs with police officers. All health care providers involved are equally responsible for making a report according to the law. When two or more health care providers know of the abuse, only one person is required to submit the reportIt is against the law for a supervisor or administrator to prevent staff from reporting abuseFile a copy of the report in the client’s medical record. Include written documentation of all communication with police officers and reporting agencies, including name(s) of individuals you speak to, the file number, and other important informationKeep the report confidential. No one can see it without the client’s consent. Since you’ve been pregnant, have you been slapped, kicked orotherwise physically hurt by someone?0-13 Weeks:NoYes, by whom? ______________ How many times? ____________14-27 Weeks:NoYes, by whom? ______________ How many times? ____________28-40 Weeks:NoYes, by whom? ______________ How many times? ____________ Within the last year, has anyone forced you to have sexualactivities?0-13 Weeks:NoYes, by whom? ______________How many times? ____________14-27 Weeks:NoYes, by whom? ______________How many times? ____________28-40 Weeks:NoYes, by whom? ______________How many times? ____________ Are your children, or have your children ever been, victims of physical abuse, sexual abuse, or neglect?N/ANoYes, please explain:__________________________According to California State law, health care practitioners must report when they reasonably suspect or have knowledge that a child is being abused and/or neglected. Refer to clinic’s mandated reporting protocol on pages 43-45. If you suspect child abuse or neglect:Interventions:Notify providerImmediately call the LA County Child Protection Hotline at: 1-800- 540-4000Within 36 hours of making this phone call, you are required to submit form SS 8572: Suspected Child Abuse Report. This report can also be completed online after calling the LA County Child Protection Hotline: You are required to report all instances of current and past child abuse and neglect as long as the victim is younger than 18 years of age. If the victim is now an adult and the abuse took place when the victim was younger than 18 years of age, you are not required to report the past abuse. However, if the abuser has access to other children and you reasonably suspect that these children may be currently in danger, you are required to report this to the LA County Child Protection Hotline at: 1-800-540-4000For additional information, refer to STT Psychosocial: Child Abuse and NeglectRefer to social worker for additional supportGroup Education ProtocolPurpose: To provide the client with perinatal education and peer support in a group settingProcedure: We will not be providing group education classes at this siteWe will be providing group education classes at this site (choose one):We will be using the March of Dimes’ Becoming a Mom/Comenzando Bien CurriculumWe will be using our own curriculum and will keep a copy of it on file for review by CPSP or Medi-CalStaffing: The following level of staff will conduct Group Education Classes (mark all that apply): N/AComprehensive Perinatal Health Worker (CPHW)RN/LVNRegistered DietitianHealth EducatorSocial WorkerOther:________________________________________________Documentation:Two or more CPSP clients comprise a group. Reimbursement is available for face-to-face encounters only. A video may be used during part of a group class, but a CPSP practitioner must be present the entire time. The following documentation is needed for group CPSP services:Maintain outlines identifying the class/group content (these should be part of the protocols)Include the date, topic, and name of the instructor on client sign-in sheetsRecord attendance at the session in each client’s record including the elapsed time (in minutes) of the sessionRetain the sign-in sheet and the group class outline or curriculum. They must be available to auditors if requested. Do not put copies of the sign-in sheet in the client’s charts because they contain information about other clients.Mandated Reporting ProtocolPurpose:To comply with all mandated reporting laws for abuse towards minors under the age of 18, dependent adults/elders, and other victims of violenceTo describe how the clinic will provide comprehensive support for all victims of abuse/neglectProcedure & Staffing:After assessing and interviewing a client, if a CPSP practitioner determines that s/he must file a report according to the mandated reporting law, it is strongly advised to follow this procedure for all mandated reports:It is recommended, but not required, that you inform the client of clinician’s duty to report. Tell her about the likely response(s) by law enforcement and what will happen.In all cases of reported or suspected abuse, telephone the proper authorities immediately, or as soon as is practically possibleWhich clinic staff person(s) will call law enforcement or the appropriate reporting agency? List person(s) by name and title:_____________________________________________________________________________Which clinic staff person(s) will file the written report? List this person by name and title: ______________________________________________________________________________Enter the name and phone number of your local law enforcement agency here: ______________________________________________________________________________Provide all the information required by law in reporting abuseInclude any special instructions for safely contacting the client, and address special needs, i.e. language needs, in the reportAll health care providers involved are equally responsible to see that the report is made according to State requirements. When two or more health care providers have knowledge of a known or suspected instance of violence required to be reported, only one person is required to submit the report. If the designated person does not follow through with making the report then the responsibility falls on the other person involved to file the report. By law, a supervisor or administrator CANNOT prevent a staff member from reporting abuse.File a copy of the report in the client’s medical record. Include written documentation of all communication with law enforcement and reporting agencies, including the name(s) of individuals you speak to, the file number, and any other critical information.Ask client what she would like to happen; advocate for the client’s needs with authoritiesWhich clinic staff member(s) will assist your client in finding resources and referrals? List this person by name and title: _________________________________________________________________________________________Which clinic staff member(s) will attend to the client while waiting for law enforcement to arrive? List this person by name and title: _________________________________________________________________________________________Which clinic staff member(s) will provide details of the alleged abuse to law enforcement if the client declines to do so herself? List this person by name and title:_________________________________________________________________________________________Keep the report confidential; it cannot be accessed by friends, family or other third parties without the client’s consentRequired Mandated Reporting Forms (See Appendix)Suspected Child Abuse Reporting Form & Instructions (SS8572, Rev. 12/2002)Suspected Dependent Adult/Elder Abuse Report Form & Instructions (SOC341, Rev. 3/2015)Suspicious Injury Report Form & Instructions (Cal OES 2-920, Rev. 2001)Danger Assessment & Body MapIntimate Partner Violence, Domestic Violence, and/or Suspicious InjuriesIf client reports stalking or terrorizing threats (with no evidence or report of physical abuse), encourage her to go to the law enforcement agency in the area where this abuse took place. Her statements will be documented and law enforcement will determine if a crime took place and should be further investigated.“Any health practitioner, who provides medical services for a physical condition to a client whom s/he knows, or reasonably suspects suffering from injuries of firearm, assaultive or abusive conduct, is required to generate a report.” (Penal Code 11160-11163.6). Additionally, if a patient reports domestic violence or has marks, bruises, or injuries caused by domestic violence: Complete the “Lethality Assessment” form, which can be found in your protocols or on the LA County CPSP website. The purpose of this assessment is to determine the level of danger and severity of the situation. The provider should document physical injuries on the body map. Call your local law enforcement agency immediately. Do not allow her to bargain with you to not call the authorities. Law enforcement can offer her an Emergency Protective Order (EPO), which is an immediate, temporary restraining order so that she can be protected from batterer.Within 48 hours of making this phone call, you are required to submit OCJP 920: Suspicious Injury Report Form and send to your local law enforcement agencyContact the LA County Domestic Violence Hotline for additional guidance: 1-800-978-3600For additional information, refer to Steps to Take: Psychosocial - Spousal/Intimate Partner AbuseRefer to your clinic protocols for a list of local shelters, counseling resources, and hotlines. Call a domestic violence shelter in your area for assistance with legal matters, housing for the client and any other questions.Notify provider of any mandated report filedNotify Psychosocial Consultant of any mandated report filed, if applicableFile any reporting forms in the client’s chart Suspected Child AbuseYou are required to file a report if you reasonably suspect child abuse, including physical abuse/violence, emotional abuse, sexual abuse, or neglect against anybody under the age of 18 (California Penal Code 11164-11173) If you suspect child abuse or neglect:Immediately call the LA County Child Protection Hotline: (800) 540-4000Within 36 hours of making this phone call, you are required to submit form SS 8572: Suspected Child Abuse Report. This report can also be completed online after calling the LA County Child Protection Hotline: You are required to report all instances of current and past child abuse and neglect as long as the victim is younger than 18 years of age. If the victim is now an adult and the abuse took place when the victim was younger than 18 years of age, you are not required to report the past abuse. However, if the abuser has access to other children and you reasonably suspect that these children may be currently in danger, you are required to report this to the LA County Child Protection Hotline: (800) 540-4000For additional information, refer to Steps to Take: Psychosocial - Child Abuse and NeglectNotify provider of any mandated report filedNotify Psychosocial Consultant of any mandated report filed, if applicableFile any reporting forms in the client’s chart Suspected Dependent Adult/Elder Abuse You are required to file a report if you suspect physical abuse, abandonment, abduction, isolation, financial abuse, and/or neglect towards any dependent adults (ages 18-64 who are physically or mentally impaired) or any individuals 65 or olderIf you suspect abuse against a dependent adult or elder:Immediately call LA County Adult Protective Services Elder Abuse Hotline at (877) 477-3646Within 48 hours of making this phone call, you are required to complete and submit the SOC 341: Report of Suspected Dependent Adult/Elder AbuseNotify provider of any mandated report filedNotify Psychosocial Consultant of any mandated report filed, if applicableFile any reporting forms in the client’s chart Postpartum Assessment and Individualized Care Plan ProtocolPurpose:To identifying issues affecting the client’s health and her baby’s health, assess her readiness to take action, and select resources needed to address the issuesTo develop an Individualized Care Plan to address any needs/issues and build on her strengthsPostpartum Assessment Staffing The following level of staff will conduct Postpartum Assessments and develop the Individualized Care Plan (mark all that apply): Comprehensive Perinatal Health Worker (CPHW)RN/LVNRegistered DietitianHealth EducatorSocial WorkerOther:________________________________________________Procedure:Refer to the Provider Handbook, Delivering CPSP Services to Clients: Postpartum Assessment and Care PlanThe Postpartum Assessment and Individualized Care Plan Tool is designed to be completed by any qualified CPSP practitioner, as defined in Title 22, Section 51179.7. The practitioner must be listed on the provider application or staff update form. A CPSP practitioner must complete the assessment face-to-face with the client in a private setting. It is not appropriate for a client to complete this form by herself or to be conducted over the phone. Conduct the assessment in a conversational manner, and use language appropriate to the client’s culture and education level when asking about the topics included in the formFamiliarize yourself with the assessment questions and the client’s medical/delivery record before completing the assessmentComplete the postpartum assessment within 60 days of deliveryResponses that are shaded are possible risk factors and usually will require additional questioning for clarification. If risks are identified, intervention(s) are needed according to the protocol, such as education, counseling, and/or referral to other CPSP support services practitioners, community based organizations, public resources, or plete all questions on the assessment form and use N/A for questions that are not applicable. If the client declines to respond to a question, document “declines to state” on the form and continue with the assessment.At the completion of the assessment, summarize the needs and strengths that have been identified and assist the client in prioritizing them. Work with her to set reasonable goals and plans and document them on the Individualized Care Plan Summary.Documentation:Client Information:Client Name: Client’s first name, middle initial, and last nameDate of Birth: Client’s month, date, and year of birthHealth Plan: Client’s health plan, if applicableID Number: If applicable, the ID number assigned to your client by your clinicProvider: The physician or other provider in charge of the client’s overall OB/CPSP careDelivery Facility: Hospital or location where the client deliveredCase Coordinator: Name and CPSP title of the Case CoordinatorIndividualized Care Plan & SummaryThe Individualized Care Plan (ICP) is integrated into the assessment form and provides a simple way to document the interventions described in the protocols. The ICP consists of education topics, specific handouts in the Steps to Take Guidelines (STT), and referrals to clinic or community resources. The protocols contain additional background information and details about each risk/problem and appropriate interventions and should always be reviewed before planning an intervention. Based on the client’s specific needs, mark the appropriate STT section(s) or handout(s) used to provide education or counseling. Each referral should be documented with the name of the person/agency and the date the referral was made. Acknowledging the client’s past and current strengths empowers her to make positive changes during the postpartum period and in the future. Client strengths should be summarized in the space provided above the Individualized Care Plan Summary. Review STT Guidelines: First Steps - Essential Elements of Every Client Interaction for examples of appropriate strengths.Problems identified on the assessment should be prioritized and summarized in the Individualized Care Plan Summary (ICP). The ICP will be a quick, brief way for the client’s CPSP team to view the findings of her assessment. In the first three columns, indicate the question number and a brief summary of the problem and goal. Use the last column to document any updates or outcomes as applicable. Describe the client’s progress towards resolving the problem. For example, was the problem resolved? What has changed since the last assessment? This information can include whether she has followed through on the referrals provided, or made changes to her behavior such as her eating or exercise habits, etc.BabyDate of birth: _________________Baby’s name: _________________□ Male □ Female Additional Information: _____________________________________ Birth weight (lbs./oz.): __________ Birth length (inches): _________ Current weight (lbs./oz.): ________ Current length (inches): _______Type of delivery: □ NSVD □ VBAC □ Vacuum □ Forceps □ C-Section (□ Primary or □ Repeat) (□ LTCS or □ Classical)Information to complete these fields should be readily available from the delivery record. Additional Information line can be used to note any other information the provider/CPHW determines to be relevant including APGAR, NICU, stillbirth, infant death, placement in foster care, etc. Clinical-DeliveryDelivery record filed in chart? □ Yes □ NoInterventions:Contact delivery hospital to obtain a copy of the delivery record, with elements including: Baby’s heightBaby’s weightApgar scoresDelivery typeComplicationsGestational age: _____________□ > 37 weeks □ < 37 weeksA copy of either the dictated delivery summary or the actual delivery room record (must be legible) should be in the chart and include the infant’s height, weight, Apgar scores, type of delivery, and any complications to the client or the baby. Interventions: Review & discuss STT Health Education handout: Did You Have Complications During Pregnancy Review & discuss STT Psychosocial: Perinatal Loss, Loss of Your Baby, and Ways to Remember Your BabyRefer to health educatorRefer to social workerInfants more than two weeks old who do not weigh more than she/he did at birth should be referred to a pediatric provider if infant follow-up care is not in placeClients who delivered their infants prematurely (less than 37 weeks gestational age) should be referred to the provider or health educator for preconception counseling/anticipatory guidance prior to becoming pregnant againClients who delivered by primary (first) C-section should be referred to the provider or health educator for counseling related to VBAC prior to becoming pregnant again, depending on the reason for C-section and type of incisionPregnancy/Delivery complications?□ No □Yes: _________________________________________Client had multiple births?□ No □ YesInterventions:Refer to STT Heath Education: Multiple Births- Twins and MoreClinical-InfantInfant has a pediatric provider?□ No □ Yes, provider: _______________________________This section provides the opportunity to assess the infant’s health and any special needs. Anyone can refer children with special needs to California Children Services (CCS). All infants born to HIV+ women should be referred to CCS.Interventions:Notify provider of infant health problemsNotify provider of infant exposure to alcohol, drugs, and/or non-prescribed medicationsRefer to STT Psychosocial: Birth DefectsEncourage the client to ensure her baby receives all checkups and immunizations as recommended by the pediatric providerRefer to CHDP providerIf the baby has not been seen by a pediatric provider and no appointment is scheduled at the time of the postpartum CPSP support services assessment, schedule an appointment for the baby before the client leavesRefer managed care members to the appropriate Medi-Cal Managed Care Member Services Department for assistance in locating a pediatric provider and establishing a “medical home” for her babyHas infant had a newborn check-up?Yes: Any problems? □ No □ Yes, describe: ________________________No: when scheduled? _______________________________Infant prenatal exposure to: (check all that apply)□ Tobacco □ Alcohol □ Drugs □ Non-prescribed MedicationClinical-MaternalHave you had your postpartum check-up?Yes, date: _________________________________________No, when scheduled? ________________________________Interventions: All health problems should be brought to the attention of the providerIf no postpartum checkup appointment has been scheduled at the time of the CPSP Postpartum Assessment, schedule one for the client before she leavesRefer to clinic eligibility workerRefer to Medi-Cal. For individuals not eligible for Medi-Cal, refer to My Health LA Any health problems since delivery?□ No □ Yes: please explain: ____________________________Do you have health insurance so you can receive your own health care in the future? Yes □ NoNutrition: AnthropometricTotal pregnancy weight gain: ________________Current weight: ____________________________Current weight category:□ Underweight □Normal □ Overweight □ ObesePostpartum Weight Goal: ____________________Most women lose more than 10 pounds during childbirth, including the weight of the baby, placenta and amniotic fluid.During the first week after delivery, new mothers will lose additional weight as they shed extra fluids — but the fat stored during pregnancy won't disappear on its own. Through diet and exercise, it is safe to lose 1-2 pounds per week. It might take six months or even longer to return to pre-pregnancy weight. Breastfeeding burns extra calories and can help a woman lose weight faster.Review client’s prenatal assessment for her height and pre-pregnancy weight. Subtract her pre-pregnancy weight from the last recorded weight prior to delivery to calculate her total pregnancy weight gain. Refer to STT Nutrition: Weight Gain During Pregnancy to find the normal weight range based on her height. Interventions: Review & discuss STT Nutrition handout: My Plate for Moms and My Nutrition Plan for Moms with the clientRefer to STT Health Education: Safe Exercise and Lifting Review & discuss STT Health Education handout: Keep Safe When You ExerciseIf the client would like to lose weight, assist her in setting a reasonable weight goal based on a loss of no more than 1-2 pounds per weekEncourage regular physical activity such as walkingReview how breastfeeding can support weight loss goalsRefer to exercise & fitness resourcesRefer to Choose Health LA Moms at: ph.LAMoms for postpartum weight loss supportRefer to registered dietitian Refer to health educator Nutrition: Biochemical (Postpartum)Blood – date collected:_______________Hgb: _______________ (< 10.5) Hct: ________________ (< 32)OGTT – date:________________Fasting: ______________ (≥ 126 mg/dL) 2 Hr: ________________ (≥ 200 mg/dL) □ N/A Comments: _____________________________________________Blood tests are used to screen for problems such as anemia, which can lead to a woman feeling more tired than normal. Postpartum hemoglobin and hematocrit levels should return to first trimester levels within 4 weeks of delivery. A client who developed diabetes during her pregnancy must have a 2-hour 75-gram oral glucose tolerance test (OGTT) 6 weeks or more after the baby is born and every year after to make certain her diabetes has gone away and has not reoccurred. These clients are at risk for developing Type 2 diabetes later in life and should also receive preconception counseling related to their diabetes prior to becoming pregnant again. Diagnostic blood glucose values (with 75gm, 2 hour OGTT):Fasting: ≥ 126 mg/dL2 hours: ≥ 200 mg/dLBoth fasting AND 2 hour values must be within range in order for results to be considered normal. You may use the comments line to provide additional information, or note if labs are pending or have been rescheduled. Interventions:Notify the provider of any abnormal valuesRefer to WIC. Clients who are anemic are considered a priority for WIC, and receive additional nutrition counselingRefer to STT Nutrition: Iron Deficiency and Other AnemiasReview & discuss STT Nutrition handouts: Get the Iron You Need, Iron Tips, Iron Tips– Take Two!, My Action Plan for IronReview & discuss STT Gestational Diabetes Mellitus handout: Now That Your Baby is HereDiscuss the importance of obtaining a checkup and preconception counseling prior to becoming pregnant againRefer to health educator Refer to registered dietitianNutrition: ClinicalFollow up needed for: Diabetes: □ Type 1 □ Type 2 □ GDMHypertensionOther: ____________________________N/AInterventions:For GDM refer to California Diabetes and Pregnancy Program (CDAPP) Sweet Success Affiliate, or a diabetes specialistRefer to provider for follow upRefer to STT Gestational Diabetes: Gestational Diabetes Mellitus (GDM), and If You Had Diabetes While You Were Pregnant: Now That Your Baby is HereReview & discuss STT Health Education handout: Did You Have Complications During PregnancyDiscuss the importance of obtaining a checkup and preconception counseling before to becoming pregnant againProvide Preconception Health Council of California handouts as applicable, available at: Are you currently taking prenatal vitamins?□ Yes □ NoInterventions:Encourage client continue to take prenatal vitamins until goneIf client is breastfeeding, encourage her to take vitamins with 400mcg folic acid dailyNutrition: DietaryDietary intake assessment completed:Perinatal Food Group Recall (PFGR)Perinatal Food Frequency Questionnaire (PFFQ)24-hour Perinatal Dietary RecallDiet adequate as assessed?: □ Yes □ NoInterview the patient and complete a dietary intake assessment. If the client is not eating the recommended servings of 2 or more food groups, then her diet is considered inadequate. The client is high risk nutritionally if she is lacking the minimum number of servings from 2 or more food groups after nutrition education has been offered and diet reassessment has been completed at her next visit.Interventions:If the client’s diet is inadequate, or if she needs education about meeting the guidelines of a particular food group, review & discuss STT Nutrition handout: MyPlate for Moms and My Nutrition Plan for Moms, highlighting the food groups she’s lacking and proper portion sizesRefer to CalFreshRefer to WICRefer to foodbankRefer to a registered dietitian if client is lacking the minimum number of servings from 2 or more food groups after nutrition education has been offered and diet reassessment has been completed, and notify providerNutrition: InfantWhat are you feeding your baby?□ Breastmilk only □ Formula only □ Breastmilk + formulaDo you have questions about mixing or feeding formula?□ Yes □ No □ N/A # Wet diapers/day: ___________________How many times in a 24 hour period do you feed your baby? __About half of mothers who started breastfeeding will still be nursing at 6 weeks postpartum. This is the time to help them picture breastfeeding working for them over the long run.Breastfeeding is the best way to feed a baby in most circumstances. Breastmilk supply is determined by how often the baby breastfeeds. A woman who tries to breast-and-formula feed her baby may have trouble maintaining her breastmilk supply.During the first week, the baby should have a minimum number of wet diapers equal to its age in days. At 6-8 weeks the number of wet diapers may decrease, but the baby should still have at least 5 wet diapers per day.It is normal for a baby to feed 12 to 20 times in a 24 hour period during the first week. As breastfeeding infants grow, they will breastfeed fewer times per day and night. It is normal for babies to have short, frequent feedings. It is also normal for them to feed on an irregular schedule. Babies should not be expected to go longer than about 3 hours in between feedings until they reach about 10 lbs (or around 2 months of age). It is not normal for a baby less than 4 months old to sleep more than 5 hours at a time between feedings. Interventions:Discuss benefits of exclusive breastfeeding for 6 monthsDiscuss risks of supplementing breastmilk with formulaRefer to STT Nutrition: Breastfeeding and Tips for Addressing Breastfeeding ConcernsRefer to WICRefer to breastfeeding education classesRefer to breastfeeding/lactation consultant Refer to breastfeeding support groupRefer to breastfeeding help lineRefer to health educatorRefer to providerIf Breastfeeding: □ N/AIs breastfeeding comfortable for you?□ Yes □ No: _______________________________________Are you planning on returning to work or school within the next 6 months?□ No □ Yes: ________________________________________Do you have any of the following concerns?□ I can’t tell if my baby is getting enough milk □ My baby is not latching on well□ I have cracked and/or sore nipples□ Other: ___________________________________________□ NABreastfeeding should be comfortable, not painful. Cracked, sore nipples are most commonly a result of improper positioning of the baby’s mouth on the breast. If a woman has pain during or between feedings or if she has any bleeding or visible cracks of the nipples, refer to a lactation expert.Interventions:Refer to STT Nutrition: Breastfeeding, Tips for Addressing Breastfeeding Concerns, and What to Expect While Breastfeeding: Birth to Six WeeksReview & Discus STT Nutrition handout: Breastfeeding Checklist for Baby and Me, My Breastfeeding Resource and Nutrition and Breastfeeding: Common Questions and AnswersRefer to Choose Health LA Moms at: ph.LAMoms for breastfeeding supportUtilize education materials which specifically address positioning if the client complains of sore or cracked nipplesRefer to breastfeeding education classesRefer to breastfeeding/lactation consultantRefer to breastfeeding support groupRefer to breastfeeding help lineRefer to WIC or provider for breast pumps and related information Provide information about Lactation Accommodation LawsRefer to providerRefer to childcare resources If formula is used: □ N/AType of formula: ____________________With Iron? □ Yes □ No__________ oz. _____________ times/dayFeeding instructions for each baby will vary based on their individual needs. The client should check with their pediatrician for specific feeding advice.In general, after the first few days, a formula-fed newborn will take about 2-3oz of formula per feeding. They will typically eat every 3-4 hours during the first few weeks. During the first month, the baby should go no longer than 4-5 hours between feedings. By the end of the first month, the baby will be taking up to 4oz per feeding, and feeding about every 4 hours. The American Academy of Pediatrics currently recommends that iron-fortified formula be used for all infants who are not breastfed, or who are only partially breastfed, from birth to one year of age. Iron-fortified formulas reduce the rate of iron-deficiency anemia in infancy, and promote the baby’s growth and development. Interventions:Provide the client with information regarding safe and appropriate bottle feeding techniques based on the client’s questions and responsesReview recommendations for iron-fortified formulaPsychosocialPatient Health Questionnaire 9 (PHQ-9)Total Score: 0-4 (None – Minimal)5-9 (Mild)10-14 (Moderate)15-19 (Moderate Severe)20-27 (Severe)The PHQ-9 is a validated nine-item tool used specifically for depression screening. Maternal depression is the leading complication of pregnancy and childbirth, striking at least?one in six?new mothers in Los Angeles County. Untreated depression can lead to bigger problems for the mother and baby if not identified and treated early. Interventions:For PHQ-9 scores of 5-9 (Mild)Refer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionReview and discuss STT Psychosocial handout: How Bad Are Your Blues?Review/provide the “Speak Up When You’re Down” brochure by Maternal Mental Health Now/LA County Perinatal Mental Health Task ForceEncourage client to inform the provider if her symptoms worsenRefer to Postpartum Support International at: 1-800-944-4773Provide referral to a mental health clinic or social worker which client can use for extra support or if symptoms worsenFor PHQ-9 scores of 10 or higher (Moderate-Severe)Notify the providerRefer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionReview and discuss STT Psychosocial handout: How Bad Are Your Blues?Review/provide the “Speak Up When You’re Down” brochure by Maternal Mental Health Now/Los Angeles County Perinatal Mental Health Task ForceRefer to Postpartum Support International at: 1-800-944-4773Refer to a mental health clinic or social worker for further evaluation, treatment, and supportCall the Los Angeles County Department of Mental Health Access Line at: 1-800-854-7771 for additional referrals, support, or psychiatric mobile response servicesRefer to local mental health urgent care clinicIf the client is a danger to herself or others, immediately call 911or your local law enforcement agencyAre you getting the support you need from your family/partner?□ Yes □ No, explain: ______________________________Are you having any difficulty coping with the demands of your baby?No Yes, explain: ____________________________________Interventions: Refer to STT Psychosocial: Parenting Stress and Emotional or Mental Health ConcernsRefer to National Parent Helpline at: 1-855-4-A-PARENT or 1-855-427-2736Refer to mental health clinicRefer to family counseling/support programRefer to Early Head Start. To locate the nearest program call: 1-877-773-5543Refer clients 18 and under to Adolescent Family Life Program (AFLP)Refer to the LA County Domestic Violence Hotline at 1-800-978-3600 or the National Domestic Violence Hotline at: 1-800-799-7233Refer to domestic violence shelterRefer to social worker for additional evaluation/support resourcesHave you had any changes in your mood since your baby was born?□ No □ Yes, please explain: ________________________________________________________________Postpartum depression affects between 10-22% of mothers. It usually develops within 3-14 days postpartum, but can develop anytime within the 1st year. Postpartum depression is different from “baby blues,” which only lasts about 2-3 weeks. If the client is still experiencing changes in mood at 5-6 weeks postpartum, she could have postpartum depression or another postpartum mood or anxiety disorder. The good news is postpartum depression and other disorders are treatable, but early assessment and treatment is key.Sleep is also important for mental health, but often it is difficult a new mom to get enough sleep. A major red flag for depression is the mother not being able to sleep, even when her baby is sleeping. It is important to ask the client if there are any problems with sleeping, since this could be a sign of postpartum depression, or other mental health problems. Interventions: Refer to STT Psychosocial: Emotional or Mental Health Concerns and DepressionReview/provide the “Speak Up When You’re Down” brochure by Maternal Mental Health Now/LA County Perinatal Mental Health Task ForceReferred to Postpartum Support International at: 1-800-944-4773Refer to mental health clinic for evaluationIf the client has a past history of serious depression, mental illness, or attempted suicides, the provider should be notified and an appropriate referral made to the social worker or mental health clinic for further assessmentCall the Los Angeles County Department of Mental Health Access Line at 1-800-854-7771 for additional referrals, support, or psychiatric mobile response servicesRefer to social workerRefer to mental health urgent care centerIf the client is a danger to herself or others, immediately call 911 or your local law enforcement agencyIf the client is currently receiving mental health services, work with the other agencies as much as possible (with the client’s written consent) to provide and coordinate servicesa) How many hours of sleep are you getting? _______________b) Are you able to sleep when your baby is sleeping?□ Yes □ No, please explain: ________________________c) Are you able to sleep if someone else is taking care of the baby?□ Yes □ No, please explain: ________________________Within the last year, have you been hit, slapped, kicked, choked, or otherwise physically hurt by someone?NoYes, by whom? ____________________How many times? __________________Within the last year, has anyone forced you to have sexual activities? NoYes, by whom? ____________________How many times? __________________Inform the client that because of your concern for her health and increased risk for violence and abuse during/after a pregnancy, you ask everyone questions about violence in the home. It is recommend, but not required, that you also tell the client that you must report abuse (if) she has current injuries from abuse, or (2) she is under the age of 18.If the client reports no abuse, tell her that if the situations changes, she should discuss it with her health care provider or CPHW.Many women will not admit abuse initially, but may discuss it later when she feels safer and more trusting of her health care providers. Do not pressure the woman to respond to the abuse questions, even when there is evidence that she is not being honest.Interventions if she reports abuse (with or without injuries):Inform the client of your mandated reporting requirement if (1) she has current injuries from abuse, or (2) she is under the age of 18Notify the providerRefer to STT Psychosocial: Spousal/Intimate Partner AbuseReview & discuss STT Psychosocial handouts: Cycle of Violence and Safety When Preparing to LeaveIf the client is under age 18, refer to STT Psychosocial: Child Abuse and Neglect and follow the mandated reporting procedure on pages 43-45.Refer to the LA County Domestic Violence Hotline at 1-800-978-3600 or the National Domestic Violence Hotline at 1-800-799-7233. Contact for additional guidance and referralsRefer to a domestic violence shelter in your area for assistance with legal matters, housing for the client, and any other questionsIf client reports stalking or threats (with no evidence or report of physical abuse), encourage her to go to the law enforcement agency in the area where the stalking took place. Her statements will be documented and law enforcement will determine if a crime took place and should be further investigatedRefer to health educator Refer to social workerInterventions if she reports abuse AND has injuries:Inform the client of your mandated reporting requirement if (1) she has current injuries from abuse, or (2) she is under the age of 18STOP the assessment and consult with the provider for help with this sectionRefer to the clinic’s mandated reporting protocol on pages 43-45The provider should complete the “Danger Assessment” form (see Appendix) and document physical injuries on the body mapCall your local law enforcement agency immediately. They can offer her an Emergency Protective Order (EPO), which is an immediate, temporary restraining order so that she can be protected from the battererWithin 48 hours of making this phone call, you are required to submit OCJP 920: Suspicious Injury Report Form (see Appendix) and send it to your local law enforcement agencyIn the report, include any special instructions for safely contacting the client, and mention special needs (such as what language she speaks)Advocate for the client’s rights and needs with the police officersAll healthcare providers involved are equally responsible for making a report according to the law. When two or more health care providers know of the abuse, only one person is required to submit the report It is against the law for a supervisor or administrator to prevent staff from reporting abuseFile a copy of the report in the client’s medical record. Include written documentation of all communications with police officers and reporting agencies, including name(s) of individuals you speak to, the file number, and other important informationKeep the report confidential. No one can see it without the client’s consentDo you feel like you have everything you need for your baby?YesNo: (please specify)clothingdiapersa safe place to sleepchildcareother:______________________________________The status of the client’s resources may have changed since the birth of her baby. This question allows the assessor to determine the client’s need for and knowledge of available resources for housing, baby supplies, etc.Interventions: Refer to STT First Steps: Making Successful Referrals and Women, Infants and Children (WIC) Supplemental Nutrition ProgramRefer to STT Psychosocial: Financial ConcernsProvide referral Los Angeles County Department of Social Services (DPSS) for financial resource programs including: CalFresh, CalWORKS, and CalLearnRefer clients 18 and under to Adolescent Family Life Program (AFLP)Provide childcare resourcesProvide housing resourcesProvide infant care supply resourcesRefer to employment resource centerRefer to social worker for assistance identifying additional resourcesHealth EducationDo you have any sore/bleeding gums, sensitive/loose teeth, bad taste or smell in mouth, or other oral health problems?□ No □ Yes: ______________________________________Interventions:Refer to dentist (FQHC dental clinic or dentist that takes Medi-Cal)Review & discuss STT Health Education handout: Keep Your Teeth and Mouth Healthy! Protect Your Baby TooHave you seen a dentist in the last 6 months? □ Yes □ NoDo you have any postpartum discomforts?□ No □ Yes: ______________________________________Interventions:Refer to provider for any discomfortsReview & discuss STT Health Education handout: Signs & Symptoms of Heart Disease During Pregnancy & PostpartumRefer to TEXT4BABY by texting BABY to 511411 (English) or BEBE to 511411 (Spanish). Text4Baby is a free service that will send her 3 health tips per week during pregnancy and the first year of the baby’s lifeRefer to registered dietitian as appropriateRefer to health educator as appropriateHave you used drugs or medications other than as prescribed in the past year?NoYes, explain: ___________________________________Interventions: Notify providerRefer client to MotherToBaby for information on medications, herbal products, infections, vaccines, maternal medical condition, illicit substances, and other common exposures such as paint, pesticides, hot tubs, etc. The client or provider can call 1-866-626-6847 or visit: Encourage client to delay another pregnancy until drug-freeRefer to substance abuse treatment Refer to Medi-Cal drug treatment facilityRefer to Narcotics AnonymousReview mandated reporting protocols on pages 43-45 if you think that client’s drug use may result in abuse or neglect to her child/children. These protocols will include contacting the LA County Child Protection Hotline and completing a Suspected Child Abuse ReportRefer to STT Psychosocial: Child Abuse and NeglectDo you drink alcohol? NoYes: □ < 3 drinks/day, 7 drinks/week in past 3 months □ > 3 drinks/day, 7 drinks/week in past 3 monthsInterventions: Encourage to delay another pregnancy until alcohol-freeEncourage to wait at least 3 hours after having alcohol before breastfeedingRefer to providerRefer to social workerRefer to Alcoholics Anonymous Refer to health educatorDo you smoke any tobacco products (including hookah or vaping), or are you exposed to secondhand smoke?NoYes: __________________________________________Infants who are exposed to secondhand smoke are at a higher risk of sudden infant death syndrome (SIDS), ear infections, coughs, colds, and other breathing problems. Interventions: Encourage not to allow smoke around the babyRefer to STT Health Education: Tobacco Use and/or Secondhand SmokeDiscuss quitting for client’s own health and for the health of her babyReview and discuss STT Health Education handout: You Can Quit SmokingRefer to California’s Smokers’ Helpline for free counseling or information on secondhand smoke at: 1-800-NO-BUTTS (1-800-662-8887) or for Spanish: 1-800-NO-FUME (1-800-456-6386)Refer to provider for additional counseling on smoking cessation or secondhand smokeHealth Education: Family PlanningWould you like to become pregnant in the next 18 months?NoYes: ___________________________________________It is usually recommended to wait at least 18 months before getting pregnant again. Spacing pregnancies 18 months allows the body to recover and be ready for the next pregnancy. Birth spacing is important because it helps both the mom and baby to be as healthy as possible. After delivery, the mother will build up her supply or nutrients and heal from any infection or inflammation. Too little time in between pregnancies can increase the risk of the baby being born premature and/or being born with low birth weight. Interventions:Discuss the importance of spacing 18 months between pregnanciesEncourage to take folic acid 400 mcg dailyEncourage to avoid chemical exposure before conceiving againEncourage preconception counseling before next pregnancyRefer to STT Health Education: Family Planning ChoicesRefer to Choose Health LA Moms at: ph.LAMoms in order to support healthy behaviorsAny plans to use birth control?Yes: ___________________________________________No: ____________________________________________Interventions:Discuss birth control methodsRefer to STT Health Education: Family Planning ChoicesRefer to family planning providerRefer to providerHas your partner ever pressured you to become pregnant, interfered with your birth control, or refused to wear a condom?NeverSometimesOftenInterventions:Refer to OB or family planning providerEncourage client to talk to an OB or family planning provider about birth control methods that are less detectable (such as a shot, implant, or an IUD with the strings trimmed)Refer to STT Health Education: Family Planning Choices Health Education: Infant Safety & CareAre you around any dangerous chemicals in your household, environment, or workplace? NoYes: ___________________________________________Interventions:Refer to STT Health Education: Workplace SafetyReview & discuss STT Health Education handout: Keep Safe at WorkEncourage to avoid lead and mercuryEncourage to avoid BPA and use BPA free bottles and formulaRefer to Los Angeles County Department of Public Health-Environmental Health for soil/water testing at: 1-800-700-9995Refer to health educatorDo you have questions about your baby’s health or safety?NoYes: ___________________________________________Maintaining the health of babies involves knowing when health problems are serious, when to get medical help, and keeping babies protected from serious disease.Safety issues for babies focus on car seat travel and safety at home. Interventions:Refer to STT Health Education: Infant Safety and Health and Oral Health During InfancyReview & discuss STT Health Education handouts: Keeping Your Baby Safe and Healthy, Protect Your Baby From Tooth Decay; Keep Your Teeth and Mouth Healthy! Protect Your Baby, Too; When Your Newborn Baby is Ill; and Your Baby Needs to be ImmunizedReinforce the importance of well child checkups and immunizations as a means of preventing illness and disabilityDiscuss safe infant sleeping positions, including “Back to Sleep” materialsReview & discuss car seat safety information in STT Health Education: Infant Safety and HealthRefer to 1-800-745-SAFE for additional car seat safety information Refer to provider as neededRefer to health educator as neededWould you like more information about the following topics? Infant bathingInfant diaperingSafe SleepSIDSCar seat safetyOther: __________________________________________N/AInterventions:Review and discuss sleeping positions, including “Back to Sleep” materialsRefer to STT Health Education: Infant Safety and HealthRefer to 1-800-745-SAFE for additional car seat safety information Refer to provider as neededRefer to health educator as neededOtherAny other outstanding issues from the Prenatal Assessment/Reassessment?NoYes: ______________________________________________________________________________________Interventions:Refer to services and provide resources as needed based on the issue that needs follow-upProvide education as needed based on the issue that needs follow-upProtocol Attachment ChecklistPlease attach the additional following documents with your protocols: Client Orientation Checklist (or equivalent)Client Orientation Brochure (Welcome to Pregnancy Care/Bienvenida a Cuidado Prenatal)Prenatal Assessment & Individualized Care PlanPostpartum Assessment & Individualized Care PlanPerinatal Food Group Recall Form & Instructions (or PFFQ or 24-hour recall)My Plate for Moms/My Nutrition Plan for MomsWeight Gain Grids & InstructionsPatient Health Questionnaire (PHQ-9)Suspected Child Abuse Report Form & Instructions (SS8572, Rev. 12/2002)Report of Suspected Dependent Adult/Elder Abuse Form & Instructions (SOC341, Rev. 3/2015)Suspicious Injury Report Form & Instructions (Cal OES 2-920, Rev. 2001)Danger Assessment & Body MapCPSP Resource & Referral Guide (Customized for your clinic)Group Education Sign-In Sheet (if applicable) ................
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